How Healthy is Healthcare in Hawaii?
Leading doctors and other experts discuss major trends and problems in Hawaii healthcare
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Raethel: Historically, healthcare in Hawaii has been paid predominantly on a fee-for-service basis. In other words, the more you do, the more you get paid. You get paid based on volume, not value, and on quantity, not quality. Fee-for-service is a terrible set of incentives for healthcare, but that’s the way healthcare has been reimbursed in Hawaii and across the country for years.
If you want to change behavior, you have to change incentives. So we are. 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 and 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.
Tenn Salle: (As a physician) I’m supposed to be the one in the group to 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?
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 in Hawaii. I’m in a nongroup 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 can’t afford the overhead, despite the reimbursements that are being put in place.
It’s important, as we develop the models, that we keep some things in mind. One is the patient-physician relationship. We have to remember that this is what it’s all about. Another is that we must create a system that will serve our entire community, not just the working middle class. We must create government policy that says we have to take care of the indigent, the poor and the medically complex. Finally, I want you to remember something that has permeated both panels today, and that is a re-evaluation of preventative care.
Green: Dr. Tenn Salle, what’s the toughest part of being a doctor in a solo practice in Hawaii?
Tenn Salle: It is a very difficult life. It’s hard work, but what keeps physicians doing it is a love for what they do.
But 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 8-to-4 jobs. My medical staff can’t justify (to the insurance companies) why I need to transfer my patient who has a complication of Hodgkin’s lymphoma in radiation therapy. I must do that. I am being more involved in administrative things and that’s not calculated into the reimbursement that doctors get either personally or into the model that we’re supposed to be responsible for.
Ushijima: Today, there are about 45 million Americans who are Medicare beneficiaries. Their number has grown by about 500,000 beneficiaries per year and at an annual cost now to the U.S. Treasury of about $600-plus billion. Now, there are 77 million aging baby boomers – people born between 1946 and 1964 – and the first of those people turned 65 in 2011. On average, there will be 4 million people per year turning 65 for the next 27 years, so Medicare enrollment is going to increase substantially.
At Queen’s, we deal with the most expensive part of the healthcare system, the inpatient area [hospitalization]. We will continue to see increasing demand as the population ages. 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. We also need to collaborate and work together as a community of providers and payers. I’m also a firm believer in investment in technology – not just information technology, but technology to improve diagnosis and treatment.
Green: Why don’t the payers alleviate the burden to providers by standardizing pre-authorized and administrative forms to decrease cost?
Raethel: Good question, and I don’t really have a good answer. 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. It would be great if we could simplify that. There have been attempts to do that but we’ve not been successful so far. But we need to continue pushing for the standardization route, which will help reduce administrative overhead.
Green: How much would standardized forms help you, Dr. Tenn Salle?
Tenn Salle: I think most practitioners look forward to that. If billing, administrative work, preauthorizations, understanding of benefits, etc., could be done online, that could be done outside of time (with patients) and streamline an incredible amount of work.
Green: How do we convince medical students to go into primary care?
Hedges: The future generation of physicians 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, and that sharing of responsibilities is one of the attractors for the current generation of trainees.
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