Collaboration to Improve
Severe & Growing
Doctor Shortages on Hawaii Island
October 21, 2010
Sharon H. Vitousek MD
North Hawaii Outcomes Project
www.nhop.org
Doctor Shortages on Hawaii Island
• The Problem
• Barriers to improvement
• Solutions
– Hawaii Island Healthcare Alliance
WEST HAWAII TODAY March 14, 2005
Dr. Doug Hiller, an orthopedist, is one of the
specialists frustrated by the system.
"You agree to leave your family for an
unlimited amount of time, at any time
during the day or night," Hiller said. "You
agree to leave an office full of patients at
any time. You agree to be exhausted the
next day. You agree not to be paid for any
of this."
WEST HAWAII TODAY March 23, 2005
“The price of practice has led to shortages
of primary care physicians and a lack of
specialists.
‘A whole generation of young doctors
didn't come here -- my colleagues and
I would have been mentoring them through
the years, but we haven't,’ said
Dr. Steven Denzer, an internal medicine
physician.
“We need your help to pressure the
legislature to reform the regulatory
climate….
Paradise isn’t paradise, when you can’t
find a doctor.”
-Jon Lattimer MD
WEST HAWAII TODAY March 23, 2005
"There should be a council of health care
providers -- doctors, hospitals, clinics,
everyone," Denzer said. "There are
common causes. It's time to
communicate and work together."
New Solution:
Island-wide
Stakeholder Collaboration
to Improve Healthcare Access
“Hawaii Island Healthcare Alliance”
Barriers to Improvement
• Fragmentation & lack of infrastructure
– Lack of Consensus on Priorities to Improve
• Healthcare is Complex
• Many players with different perspectives
–
–
–
–
–
–
Patients
Providers, Hospitals, MD, “Mid-level providers", RN etc
Government/Regulatory
Payers/ Insurance
Vendors- Equipment/Pharmaceutical suppliers
Purchasers/Business/Individuals
• Hospitals (which often lead) are facing their
own financial troubles
• Mostly solo and small group practices
• Cost of the problem NOT clear
Who has taken lead ?
•
•
•
•
•
•
•
•
•
•
DOH?
SHPDA? SAC
Legislature/ Legislators?
County: Mayors office, R&D, Office of Aging?
Hospitals/ HAH?
Doctors/ PA’s/HMA?
FQHC’s, Primary Care Association?
HRHA, HIRHA?
JABSOM?
Chambers/ Business? Insurance?
Hawaii Island
Healthcare Alliance
Providers
Community
Business
Alliance
Education
Government
Insurance
Alliance
• Can reduce fragmentation
• Can provide vehicle for:
– Collaboration & Connecting with resources
– To clarify common vision, measures of
success:
– Policy change
– Reduce barriers to improvement
Can accelerate Improvement
Alliance Members
• Providers: Hospitals, FQHC, Docs, PAs
JABSOM, CHI
• Business: Chambers
• Community
• Government: DOH, SORH, Mayor’s Office
• Workforce investment
• Unions
• Insurance
• Advocacy
Guiding Principles
•
•
•
•
•
Island wide approach
Collaborative
Inclusive
Importance of Primary Care & Prevention
Short term & Long term strategies
Focus
• Improve access to primary care and
specialist care
• Support financially stable hospitals
Alliance Priorities
• UH Family Practice Residency!
• Administrative flexibility for HHSC hospitals
• Identify & Address policy barriers: effective &
safe use of broader primary care team: (PA’s,
RNP’s, midwives) use of phone/ telemedicine,
tort reform
– Dialogue to promote consensus to Legislature
• Focus on Primary Care - Medical Home
– Broader team of providers, PA’s, RNP
• Reduce gap between cost of providing care &
reimbursement
• Collaboration on Recruitment & Retention
Alliance Accomplishments
Recommendations to 2009 Legislature
Consensus on need for UH Hilo Family
Practice Residency program
Consensus on need for collaborative
recruitment & retention
Identified policy barriers to effective PA
practice -worked with Medicaid on change
Work force training on revenue cycle
Planning to align 2010 policy efforts
Organizational Infrastructure
Vehicle- Fiscal Agent selected- FOF
Decision making- Charter
Exec com, Officers to sign
Need Funding for Infrastructure
•
•
•
•
Admin/ partnership development
Communications
Information gathering/community meetings
Grant writing
Collaboration on
Recruitment & Retention
Providers
Regional & Island wide planning for:
Services
Specialists & call
Develop more opportunities to join a
group practice or IPA
Increase opportunities for qualifying for
loan repayment through NHSC
Recruitment & Retention
JABSOM/ Providers/ Business
Develop updated accessible list of
current docs with contact info
Develop updated accessible list of
current “job opportunities” and contact
info for prospective recruits.
Recruitment & Retention
Government
Implement “Island status” to add COLA
to CMS reimbursement
Improve HPSA /MUA designations
Technical assistance with getting NHSC
qualification to help fund loan
repayment
Health Enterprise Zones
Recruitment & Retention
Insurers
Pilot test different reimbursement for
Primary Care Medical Home
Work force training on revenue cycle
Reduce barriers to appropriate charge for
phone communication with own patients
Improve information on cost by sharing
data on Avoidable Hosp/ER costs
Recruitment & Retention
Community
Improve community links with existing
students and residents FROM Big Island
Improve community links with families of
prospective and new & existing docs,
• Link with business startup loans
• Link with loan repayment opportunities,
What is our preferred future
for next two years? --DRAFT
• Hilo Residency students start in 2013
•
•
•
•
•
3 High quality, financially stable Acute Hospitals
4 High quality Critical Access Hospitals
3 High quality FQHC
At least 10% increase in SNF beds
Adequate & Satisfied healthcare workforce
– Retain, recruit at least 30 new physicians –
X (20) primary care, Y (10) specialists, Z PA’s
What is our preferred future
for next two years? --DRAFT
• 90 % of population has a primary care
medical home
• 80 % Have “visited doctor in last 2 yrs”
• 5 % decrease in “Potentially Avoidable
Hospitalizations”
What is our preferred future
for next 5-10 years? --DRAFT
• Ratios of doctors/population same as state
average
• Hawaii County has same proportion of doctors
as population ie 14 %
• Hawaii County death rates are at or below state
average
• Hawaii County life expectancy is at least as high
as the state average
Why do we think
a stakeholder collaboration
will really work?
Its worked elsewhere!
Lessons Learned
Addressing Complex Problems
• Credible, compelling data engages stakeholders
• Complex issues require multiple stakeholders
– State, County & National
 Funding for infrastructure is essential
• Prioritization & Short key messages
• Specific recommendations
– Including Policy Change
• County leadership makes a big difference
• Complex issues take time
– to address barriers and to show results
Growing Sense
of Shared Responsibility
It Is Our Monkey
PROBLEM
Quantitative
How Big is the Problem?
Sources of info:
1. Census data on # of MD offices
2. Ratios: doctors / population
3. % of licensed state doctors IN HC
compared to % of population
4. Population Surveys on access
5. Big Island Workforce Study
Number of Hawaii County
Physicians Offices (2001- 2007)
155
151
150
150
1%
146
146
145
3%
7%
140
-10%
137
136
136
135
1%
Code: 621111 Title: Offices of physicians (except mental health specialists)
Sector: 62 Definition:
This industry comprises establishments of health practitioners having the degree
of M.D. (Doctor of medicine) or D.O. (Doctor of osteopathy) primarily engaged in
the independent practice of general or specialized medicine (except psychiatry or
psychoanalysis) or surgery. These practitioners operate private or group practices
in their own offices (e.g., centers, clinics) or in the facilities of others, such as
hospitals or HMO medical centers (U.S. Census-Economic Census).
130
125
2001
2002
Chart: North Hawaii Outcomes Project - October 2009
2003
2004
2005
2006
2007
Source: U.S. Census, Economic Census 2007
Hawaii County
Lowest Ratio of MD/Pop
Licensed physicians per 1,000 pop
*Current Physician licenses as of April 1, 2009
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
3.4
3.1
State
2.4
2.1
2.3
Hawaii
County
City & County Maui County Kauai County
Of Honolulu
Chart: North Hawaii Outcomes Project,
Source: Numerator from Department of Commerce
and Consumer Affairs – April 1, 2009
*Licensed physicians may or may not be actively practicing
This number OVER estimates physician supply
Percent Population by Counties
Kauai County, 5%
Maui County,
11%
Hawaii County,
14%
Honolulu County,
70%
Chart: North Hawaii Outcomes Project - October 2009
Source: U.S. Census March 19, 2009 Population Estimate
Percent of Licensed Physicians - 2009*
*Current licenses(7,608) as of April 1, 2009
Foreign
1%
Hawaii County
5%
Note: The Mainland and
Foreign categories are licensed
physicians who have a license
to practice in Hawaii but use a
mainland address as their
primary address.
Hawaii County
Mainland
47%
City & County Of Honolulu
City & County Of
Honolulu
41%
Maui County
Kauai County
Mainland
Foreign
Kauai County
2%
Chart: North Hawaii Outcomes Project,
October 2009
Maui County
4%
Source: Numerator f rom Department of Commerce and Consumer Af f airs – April 1, 200
*Denominator f rom U.S. Census March 19, 2009 population estimate
** Licensed physicians may or may not be active.
~20 % Do Not Have Doctor in Hawaii County
Percent of People Who Do Not Have One Person They Think of As Their
Personal Doctor - 2001 - 2008
50%
45%
BRFSS phone survey may underestimate problem
40%
35%
30%
25%
20%
15%
10%
5%
Hawaii County
City & County of Honolulu
Kauai County
Maui County
0%
2001
2002
2003
Chart: North Hawaii Outcome Project - October 2009
2004
2005
2006
2007
2008
Source: Behavioral Risk Factor Surveillance Survey 2001 - 2008
Visited a Doctor Within the Last Two Years
2005-2008
86.0%
83.9%
82.5%
Percent visited a doctor
81.5%
81.9%
79.7%
78.2%
76.0%
77.3%
77.1%
78.8%
77.9%
76.9%
76.4%
75.7%
75.3%
74.0%
72.9%
66.0%
2005
2006
2007
2008
Kauai County
77.1%
76.4%
75.3%
72.9%
City & County of Honolulu
83.9%
82.5%
81.9%
79.7%
Maui County
81.5%
78.2%
78.8%
75.7%
Hawaii County
77.3%
76.9%
77.9%
74.0%
Chart: North Hawaii Outcome Project - October 2009
Source: Behavioral Risk Factor Surveillance Survey 2005 - 2008
Kelley Withy, MD, PhD
withy@hawaii.edu
David Sakamoto, MD, MBA
dts@hawaii.edu
UH John A. Burns School of Medicine
Area Health Education Center
808-692-1060
Additional Issues Increasing
size of the Problem?
• Aging Health workforce Average Age MD = 56
• Aging Population
• Relatively Higher Burden of Disease:
– Social determinants
• Increasing Poverty- Increasing Income inequality
• Low educational attainment
• Rural & Geographic isolation
Consequences of Shortage
Consequences of the Shortage
Higher admission rates for “potentially
avoidable Hospitalizations” (ASC)
1. HTN
2. CHF
3. Pneumonia
Hypertension Rate
2005-2007
35
Number of admissions per 100,000 population
32.4
30
25
22.8
20
20.5
19.8
18.6
16.4
15
10
5
Hawaii County
State
0
2005
Chart: North Hawaii Outcomes Project - October 2009
2006
2007
Source: Hawaii Health Information Corporation
Congestive Heart Failure Rate
2005 - 2007
360
350.2
348.3
Number of admissions per 100,000 population
350
340
338.2
333.6
330
320
315.3
310
306.4
300
290
Hawaii County
State
280
2005
Chart: North Hawaii Outcomes Project - October 2009
2006
2007
Source: Hawaii Health Information Corporation
Pneumonia Rate
2005 - 2007
400
350
323.1
Number of admissions per 100,000 population
345.6
298
300
311.9
296.5
286.5
250
200
150
100
50
Hawaii County
State
0
2005
Chart: North Hawaii Outcomes Project - October 2009
2006
2007
Source: Hawaii Health Information Corporation
Consequences of the Shortage
Higher Death Rates
1.
2.
3.
4.
All causes
Overall cancer
Infant death rates
Stroke death rates
All Causes - Age-Adjusted Death Rate
Hawaii County Compared to the State
Consequences
1000
Hawaii County
State
Age-Adjusted Rates per 100,000 population
900
800
700
600
500
400
300
200
100
0
1999
2000
2001
2002
Chart: North Hawaii Outcomes Project - April 2009
2003
2004
2005
2006
2007
Source: Office of Health Status Monitoring, 1999-2007
Overall Cancer - Death Rate
Hawaii County Compared to the State
Consequences
500
450
Hawaii county
Deaths per 100,000 age-adjusted population
State
400
350
300
250
200
150
100
50
0
1999
2000
2001
2002
Chart: North Hawaii Outcomes Project - April 2009
2003
2004
2005
2006
2007
Source: Office of Health Status Monitoring, 1999-2007
Infant Mortality (County of Residence)
Average Rate 2000-2007
8.0
Rate of infant deaths per 1,000 births
7.0
6.7
6.6
6.0
5.3
5.0
4.7
4.0
3.0
2.0
1.0
0.0
Hawaii County
City & County of Honolulu
Chart: North Hawaii Outcomes Project - October 2009
Kauai County
Maui County
Source: State of Hawaii Health Department, Vital Statistics
Stroke Death Rates by County
Average Age-Adjusted (1999 - 2007)
100.0
90.0
80.0
70.0
60.0
64.1
State
50.0
50.2
40.0
46.4
45.3
HP 2010
30.0
20.0
10.0
0.0
Hawaii
Chart: North Hawaii Outcomes Project, April 2009
Honolulu
Kauai
Maui
Source: Department of Health - Office of Health Status
Monitoring, 1999 - 2007
Evidence Linking Death Rates
with Access to Primary Care
Harvard/ Hopkins study of all US Counties
Protective Factors
Ratio of Primary
Care Physicians
Education Level
“Social Cohesion”
Source: Leiyu Shi, Ichiro Kawachi, Ph.D. Income Inequality,
Primary Care, and Health Indicators J Fam Prac 1999 48: 275-284
Life Expectancy at Birth, by County
2005
84.0
83.0
82.0
81.0
80.9
80.7
80.6
Kauai
Maui/Kalawao
80.0
79.7
79.0
78.0
77.0
Hawaii
Honolulu
Chart: North Hawaii Outcomes Project - September
2009
Source: Hawaii State Data Book 2008
Consequences of the Shortage
• More complications?- NEED DATA
• More ER visits?
- NEED DATA
• Higher costs?
- NEED DATA
Root Causes
Summary of Causes:
• $$- Can’t make it financially
• Time & work life balance:
– Too much call,
– High volume required to make ends meet,
– Lack of docs to refer to, impacts life style
• Isolation:
– Professional
• Solo practice or small groups, Too busy
• Long distances, lack of leadership
– Social family
Causes:
$$$--- Cant make it financially
• Large & growing financial gap between
cost of providing care and reimbursement
Worse with solo/ small practices
– Worse with more Underinsured, Uninsured, &
Unemployed
– Worse with high cost of living--housing,
education
– Worse with no COLA
Hawaii Lowest Medicare Spending
per Beneficiary
Impact on Quality and Access
Source: “Medicare Spending, the Physician Workforce
And Beneficiaries’ Quality of Care”
Health Affairs
Katherine Baicker and Amitabh Chandra,
7 April 2004
Hawaii island Healthcare Alliance
Source: “Medicare Spending, the Physician Workforce And Beneficiaries’ Quality of Care”
Baicker & Chandra, Health Affairs ,7 April 2004
Acknowledgements
• Data collected analyzed displayed by
NHOP form primary & secondary
soruces
• www.nhop.org supported by the
• Earl & Doris Bakken Foundation