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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Green: So far today, we’ve heard from our panel, from Jerris, about a new way to train more physicians and basically a new track of physician training. From Hilton, we’ve heard an expansion of a new model that is pushing money towards primary care and prevention. From Dr. Tenn Salle, we’ve heard what is really like to practice in the trenches and what the difficult part about being a physician is, about the time that you lose with your patients these days, and then from Art, we’ve heard about the crisis that may exist for long-term care and the economics of the hospital. And that takes me to our first question. Art, someone asked, if we do our job to keep patients out of the hospital, then why will we need more beds?
Ushijima: It’s not so much that we’re not trying to keep patients out of the hospital, because there are lots of efforts going on throughout the community and nation to do that, but people will still just get sick, and will get injured from trauma. People age and our bodies deteriorate over time and some point in time people are going to have to be hospitalized.
Green: And have you seen more people being admitted or less over the last 10 years?
Ushijima: Statewide the numbers are increasing. Hawaii has low utilization rates compared to the national, but the total number of admissions is growing statewide, although at a slower rate than nationally. We need to continue to invest in technology because as we’ve invested in technology we then have been able to keep patients out of the hospital. For example, when I started in healthcare back in 1973, there was one CT scanner per million in our population. What I’ve seen over time with investment in technology is that there is little or no exploratory surgery on the surgical schedules today. We’ve been able to by investing in technology and the capabilities of people that we’ve been able to provide better care and also keep people out. At the same time, the demand still continues to increase.
Green: Now I’m going to rapid fire questions and if we can get 15-second answers... I just want to see how many questions I can get to for our audience. I think this is to Hilton. Why don’t the payers alleviate the burden to providers by standardizing pre-auth and administrative forms to decrease cost?
Raethel: Good question. I don’t really have a good answer for that, but there is a group of health plans that are working on doing that. There are a lot of complexities, and the payers all have their own rules. Medicaid, Medicare, Quest plans, Quest Expanded Access plans, Worker’s Comp — a lot of different players. It would be great if we could simplify that. There have been attempts to do that but to date we’ve not been successful but it’s something we do need to continue pushing for the standardization route and reducing administrative overhead.
Green: How much would that help you, Dr. Tenn Salle, if the forms were standardized? Would that change your day?
Tenn Salle: I think most practitioners look forward to that. Electronics or previously, we’re filling out forms. If billing, administrative work, pre-authorizations, understanding of benefits, etc., could be done online this could be done outside of time (with patients) and it would streamline an incredible amount of work.
Green: If someone asked you today, would you rather have more money for your practice or more time, what would you answer?
Tenn Salle: Time.
Green: To the Dean: What are we going to do when doctors no longer wish to practice medicine? How are you going to convince primary care doctors to go into that discipline if the insurance companies propose programs with lots of hoops and then the doctor has to tweak each individual patient?
Hedges: The generation of the future physician is looking at having a balanced life. Although, reimbursement is important, paying educational debt is critical. There’s still the reality that there will be more group practice, more shared practice activity of the future. So, one of the attractors for the current generation of trainees will be practice environments that allow sharing of responsibilities and more personal time and so as we build such activities we really need to focus on how they work now as a solo practitioner but as collective physicians.
Green: Why are Hawaii’s healthcare costs lower than other states? Are we offering the right level of care or can they go even lower? Hilton?
Raethel: We are very fortunate with the rate of healthcare spending in Hawaii even though we do have issues, but one of the reasons we have a lower overall spend is the Prepaid Healthcare Act that does require health insurance. So, between the Prepaid Healthcare, Quest, Medicare, and the Quest Expanded Access Programs, we do have very broad coverage and that does spread the cost of healthcare. And before we had that, we had genetic factors because of the population here. We (generally) have a very healthy lifestyle. We have a healthy environment. I’m not saying we don’t have a lot of issues but those are some of the factors that would contribute to us having a lower spend in many other parts of the country.
Green: If you want to become a physician, you go through medical school. First, you go through college. So, four years of college, four years of medical school, plus three years of residency at the minimum. You are at least 30 years old before you’ve had your first job, and then you have to pay those education loans back, which now average well over $150,000 I think. Dean, what’s the average number or minimum amount of debt for a graduate this year?
Hedges: Well, nationally it’s about $180,000 upon graduation. We are doing a bit better here. It’s about $80,000 in Hawaii in the large forecast because most of our students are from Hawaii and many of them are living with family. Of course that creates a burden on the family but they’re ending up with only about an $80,000 debt upon graduation.
Green: I just wanted to punctuate that point. I don’t think physicians send you a complaint about salaries. I don’t, but if you do that quick calculation, you’re really talking about from the age of 20 until 40 averaging out those costs and debt and so on. Physicians are making $70,000 or $80,000 per year, in which those are the years you want to start a family and I think therein lies one of the issues, though nobody should complain about making a decent living and taking care of their family. That’s an important take-home message when you hear doctors complaining about the system or complaining about going into a special discipline, because they vary very greatly. That is one of the conundrums of getting people to go into primary care when they’re dealing with those regular questions of how are they going to pay back their debt? Would this panel support absolute loan repayment for all primary care individuals and would their organizations be willing to contribute some either mentorship or dollars to that private initiative to get people into primary care? Dean Hedges?
Hedges: It is a challenge because you want to make sure that this is a sustainable operation and having it at a point where people are ready to take that first job and this is tied to their first job — I think that is an incredibly important motivator.
Green: Hilton, is it working investing dollars in primary care training? Is it from an economic standpoint?
Raethel: Absolutely, we as I said in my five minutes, we’re investing very heavily in primary care. We believe that there is a lot of unmatched opportunity to expand the role of primary care and we are looking at a variety of avenues to support the expansion of primary care in the state of Hawaii including working with the school of medicine.
Green: Nadine, would it be worth taking on a student with you in practice even if it took some of your time, if it meant getting that student into primary care and paying back their loans?
Tenn Salle: Absolutely. Having incentives both on a medical school level, residency level, and later on as professionals to encourage individuals to go to primary care are all excellent choices. The one thing though that does need to be put in place is you can have scholarships. You can have incentives that will encourage young physicians to go into primary care. The question is not whether they will go in, it’s whether they will stay and we’re dealing with very intelligent people here. At some point, they’re going to look at the business model and if the business model doesn’t make sense they won’t stay. If they’re working 12 to 14 hours a day, Saturdays included if you’re in primary care, and you are barely making what your contemporaries are making, they’re going to question why should I do that? Why should I be away from my children?
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