How Healthy is Healthcare in Hawaii? - Extended Version
Leading doctors and other experts discuss major trends and problems in Hawaii healthcare
(page 7 of 8)
Dr. Nadine Tenn Salle (Hawaii Independent Physicians Association): I’m supposed to be the one in the group to sort of bring it all together, because after this entire transformation takes place, the question is, will you be satisfied? Can I actually practice under the model that is created? In five or 10 years, will you, I, your child, your parents, be able to find a quality physician and be able to access treatment in a timely manner?
To give you a sense of what perspective I’m coming from, I’m in solo practice. I practice at Queen’s. I’m involved with internal medicine, which is adults, and pediatrics. So, I’m a little bit of a typical private practitioner here in Hawaii. I’m in a non-group practice. I’m located fairly close to a major hospital but I’m also a dying breed. I am actually a breed that may not survive this healthcare transformation because practitioners such as myself, despite the reimbursement that is being put in place, can’t afford the overhead. In addition to that, as Dean Hedges referred to, my young colleagues are choosing to go elsewhere.
They’re going out of private practice. They’re deciding not to practice within the state of Hawaii, much less the neighbor islands. It’s important that as we develop the models, as we come together, as we try to collaborate to make this system work — because it is that important and it is that lucrative, and it is as Dr. Tsang, said a petri dish that if we do it right it could actually work — I would like to keep at least four things in mind. No. 1 is the patient-physician relationship. We have to remember that this is what it’s all about.
The second is that we do create a system that will serve our entire community — not just the working middle class, and to create government policy that says that we have to take care of the indigent and the poor and the medically complex.
The third thing I would like to put before you is this: As venture capitalists and people who like to practice at the top of business, physicians also like to practice at the top of their game. When this model is created, I think physicians will want to be able to practice at the top of their game and not be surrounded by things placed on them by business models and insurances. The final thing I want you to remember is something that has permeated both panels today, and that is a re-evaluation of preventative care, which we believe will probably be housed under the patient family-centered medical home.
Understand that there might not be immediate economic payback on preventative care but I think just common sense tells us that there is a long-term payback for preventative care. Preventing people from being obese so they will not become diabetic, or if they do, they will become an easily controlled diabetic, and will not have hospitalizations and cardiac complications. Oh, I forgot my word. My word was sustainability. Can we create a system that can actually last and actually survive practically?
Green: Dr. Tenn Salle, what’s the toughest part of your day as a provider, and in that context, is there something that comes to mind that someone who is a big thinker or an investment broker or an investment capital-type person in this room might be able to help with that? So, what’s the toughest part of being a doctor today for you?
Tenn Salle: Everybody sort of knows the tale of being a physician. It is a very difficult life to lead. It’s hard work but what keeps physicians doing it is a certain amount of love for what they do. What is happening — and I’m young enough yet old enough to see a contrast — is physicians are increasingly being pulled away from what they love to do, which is actually take care of patients. My day often starts around 4:30 in the morning, and I just get home to put my children to bed around 7:30 or 8 at night — and that’s if I don’t get called back to the hospital. My day is popping in and out of rooms — literally. I’m taking care of a patient, and then I have to step out because I need to speak to the insurance company — because they work in an 8 to 4 job. My medical staff can’t justify why I need to transfer my patient who has a complication of Hodgkin’s lymphoma in radiation therapy. It is me that has to sit down and do that. I am being more and more involved in administrative things. That’s not necessarily a complaint, but it’s also not calculated into the reimbursement that doctors get either personally or into the model that we’re supposed to be responsible for.
Green: So, you’re saying that they need technology to help alleviate that problem of taking you from one of your patients?
Tenn Salle: Absolutely, I’m a big fan of technology.
Art Ushijima (Queen's Medical Center): My two words (I’m going to cheat) are aging and beds. Recently, I heard a statistic that there are 70,000 Americans who are 100 years or older today. By the year 2050, which is less than 40 years from now, that number will grow to one million. Some of you in here today will live to be 100. I’m going to share some statistics today and you may challenge the validity or reliability of this statistics, but the magnitude I think is what you really need to be attentive to and I’m really focusing on the Medicare population.
So today, there are about 45 million Americans who are Medicare beneficiaries. Historically they have been growing about 500,000 beneficiaries per year and at an annual cost to the U.S. Treasury of about $600-plus billion a year. Now, there are 77 million aging baby boomers — people who were born between 1946 and 1964. The first year of that group — those born in 1946, those people turned 65 in 2011. If you average the birth rate of those born between 1946 and 1964 — there will be more than four million people per year turning 65 for the next 27 years, So the Medicare enrollment is going to increase substantially.
So the cost impact of the Medicare program is going to continue to escalate and that’s really the big financial issue that is facing the country today with respect to Medicare population. In Hawaii, we have more than 1.2 million people today and approximately 16 percent of the population is 65 and older and that the annual cost of Medicare is about $850 million or close to $1 billion a year.
Hawaii has one of the lowest reimbursements in the nation for Medicare. The cost per enrollee for Medicare is about $5,300 per enrollee in the state of Hawaii. Nationally, it’s about $9,300. In the city of Miami, it’s about $16,500; there are significant disparities in the cost of Medicare across the country. By 2030, about 22 percent of the population of Hawaii (which itself is expected to increase to more than 1.5 million) is expected to be 65 or older, and just using today’s costs, the annual costs of Medicare will rise to approximately $2 billion.
At Queen’s, we’re trying to anticipate what the care delivery needs will be, what the bed needs will be, and what the ancillary service needs will be. Today, the age group from 64 to 74 has between 23,000 and 25,000 inpatient admissions each year. If you project that forward to 2030 that number goes to nearly 50,000 inpatient admissions. That’s assuming that things continue as is and so that age group – that demand for in-patient beds will increase. Right now, we’re estimating about 350 more additional beds will be needed statewide, on top of the 3,000 beds in the state today. How do we deal with that?
At Queen’s, what we deal with is the most expensive part of the healthcare system and that is inpatient (hospitalization) area and we will continue to see increasing demand as the population ages. I think strategically we need to look at how we’re going to function and to improve services at the primary care level to keep patients out of the hospital. We need to concentrate services to achieve scale and to provide as much of the services on an outpatient basis. I think we also need to collaborate and work together as a community of providers and payers. I’m a firm believer also in investment in technology — not just information technology but technology to improve care in terms of diagnosis and treatment.
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