by Edwin Quinabo
The shortage of doctors is like the chest pain that went ignored but can no longer be left to destiny to settle. Over the years health experts warned about the shortfall. The data raised eye brows; but not the will to enact corrective measures. At least, to the scale and scope it deserved, public health professionals say.
Then last year COVID-19 swept through communities, triggering an avalanche of greater urgency as older doctors –whomped by the economic downturn – called in their careers, hung up their stethoscope and white overcoats for good. Early retirement forced at the hand of COVID-19 exacerbated an already bleak prognosis to the physician shortage; and communities now face potentially frightening consequences.
What? Possibly not getting proper patient care or having to wait longer at the doctor’s clinic or even to book an appointment. Or worse yet, not finding a primary care physician to the patient’s comfort, having to travel out-of-state to get certain specialized treatment, or paying higher prices for consultations. Patients could also resort to ER visits for non-emergency health issues.
Kelley Withy, MD, MS, PhD, Director of the Hawaii/Pacific Basin Area Health Education Center, says it could also mean, “that if you need a doctor urgently, you might die because you might not be able to access that.” This is the gravity at hand.
What it could mean for the Filipino community? Dr. Charlie Sonido, one of the medical directors of Hawaii Filipino Healthcare (HFH) group and CEO of Primary Care Clinic of Hawaii (PCCH), one of the state’s largest independently- owned private practices, said “the Filipino community is in for a big shock. It will be harder and harder for them to find a primary care physician in the next few years who understands their culture because their own physicians are retiring and there is no one to replace them.”
He said, “There is an acute shortage of Filipino physicians in Hawaii to take care of the unique healthcare needs of the growing Filipino immigrant population.”
By the numbers Nationally and in Hawaii
The Association of American Medical Colleges (AAMC) published data on June 26, 2020 that estimates a physician shortage nationally between 21,400 and 55,200 for primary care physicians by 2033. Of all physicians that include primary and specialty, the shortfall could be as high as 139,000 by the same time period.
Researchers at the John A. Burns School of Medicine in its Hawai’i Physician Workforce Assessment Project Report for 2020 found the Hawaii’s physician shortage is between the range of 710 to 1,008. There are 10,227 physicians licensed in Hawaii; 2,812 full-time physicians (FTEs) in Hawaii compared to what is needed, estimated at 3,529 statewide.
The estimated shortage by counties: Oahu 475, the Big Island 287, Maui 185, Kauai 61.
The largest shortage statewide is in the area of Primary Care (Family Medicine, Internal Medicine, Pediatrics and Geriatrics) that is estimated to be below the needed 412 full-time physicians.
Researchers say all subspecialties across the board statewide is down. Areas most underrepresented are Colorectal Surgery, Pathology, Pulmonary, Infectious Disease, Allergy/Immunology and Hematology/Oncology.
Dr. Withy said of the UH Workforce Report, “The main finding in my mind is that we now have 1,000 fewer physicians that if we were on the US Continent. This is terrifying. In fact, the Big Island has over a 50% shortage. This is largely caused by low reimbursement, high cost of living and a medical infrastructure that does not offer the support physicians need.
“In fact, our physicians are more likely to be employed than private practice physicians, and employed physicians can only work where there is a large medical group. So rural areas with private practice doctors are going to suffer severely as these older physicians retire or die.”
Lt. Gov. Josh Green, MD, told the Filipino Chronicle, “We have continued to wrestle with the physician shortage, which has tended to be 20% or more on Oahu and significantly worse on the neighbor islands. This is a challenge made tougher by the pandemic, as many doctors had to suspend their practice for several months during the COVID outbreak.”
In the same report, 989 physicians’ offices were questioned about the impact COVID-19 had, 44% said that the coronavirus pandemic disrupted their practice in the form of temporary and permanent clinic closures, early retirement, increased telehealth practice, altered operating hours and locations and reduced patient volume.
Dr. Josephine Waite, a solo practitioner who has 21 years of practicing medicine, explains how COVID impacted her practice. “Many of our patients work in the entertainment and food industry. While tourism was down and lockdowns were enforced, many of our patients lost their job and subsequently their insurance.”
Studies show that when workers don’t have health insurance, they tend to visit their doctors less frequently due to cost.
Adding to this, Dr. Waite said patients were also reluctant to come to the office for fear of contracting COVID-19. “The office flow slowed down as preparations for PPE, sanitation and disinfection added to time spent for each patient.”
She, along with other doctors report that one upside during the pandemic time has been telehealth that afforded continued care to patients via the internet. At the same time, Dr. Waite said technical difficulties such as slow internet and signal variability prolonged the total time spent with each patient. “And for those of us who have many elderly adult patients- this [telehealth] challenge is compounded as most are not tech savvy.”
Dr. Waite said telehealth has also been a challenge for older physicians. “Those [physicians] older than 65 who are not as tech savvy, some have opted to retire.”
Dr. Withy confirmed, “COVID has forced many older docs to retire and some to pass away. It has forced many others to go to telehealth modalities which are not as effective as face to face care.”
Health experts believe even when the pandemic is over, there could be a rebound, but not enough to fill the shortage even if all physicians returned to full-time practice.
“The Filipino community is in for a big shock. It will be harder and harder for them to find a primary care physician in the next few years who understands their culture because their own physicians are retiring and there is no one to replace them. There is an acute shortage of Filipino physicians in Hawaii to take care of the unique healthcare needs of the growing Filipino immigrant population.”— Dr. Charlie Sonido, a medical director with Hawaii Filipino Healthcare (HFH) group, CEO of Primary Care Clinic of Hawaii (PCCH)
REASONS FOR PHYSICIAN SHORTAGE AND POSSIBLE SOLUTIONS
Reason #1: Older Physicians Retiring, Decreasing Work hours
At least 110 Hawaii physicians retired in 2020, 120 decreased their work hours and eight passed away. Of the active physicians, 46% are ages 55+, 21% are ages 65+ and one is 90 years old.
The aging of physician is one half of the shortage problem. The other half is the increasing population of seniors. Approximately 10,000 Americans turn 65 every day, according to the Pew Research Center. The over-65 population will increase by 50% by 2030, putting additional strain on the health care delivery system. Older adults traditionally use more health care and specialty services than younger populations due to a higher incidence of chronic conditions and age-related illnesses, the AAMC reports.
Reason #2: Not Enough New Physicians are Coming to the state
An aging physician workforce and retirement wouldn’t necessarily be unique to Hawaii, but the problem is there isn’t sufficient numbers of younger or new physicians coming to practice in Hawaii to fill the gap.
Possible Solution #1 Loan Repayment Program
State assistance in helping new doctors with their educational loans is one area the state has looked at to incentivize doctors to practice in Hawaii. The Hawaii State Loan Repayment Program (HSLRP) provides qualified physicians working in high-need areas with loan repayment. You must commit to working full-time for 2 years, or half-time for 4 years.
HSLRP is a federal grant to pay off educational loans for primary care and behavioral health providers who care for patients at non-profit organizations in designated Health Professional Shortage Areas of Hawaii. The areas of shortage, requirements and application information for the program could be found at https://www.ahec.hawaii.edu/physician-recruiter/resources-physicians/loan/.
There has been success in recruitment to Hawaii because of the loan repayment program but it needs federal assistance to maintain. Lt. Gov. Green said the repayment program is a great incentive to bring in doctors to the state but he said it is difficult to fund fully during these tough times. “If we seeded $5M a year into the program we could repay all loans for those who commit to Hawaii and have no shortage. This investment would be worth 20x the cost immediately in healthcare savings from better care.”
Dr. Withy said, “Loan repayment has helped to recruit and retain 39 healthcare professionals over the last 8 years, but without local matching funding for the hundreds of thousands provided by the federal government, the program will be scratched.”
The loan repayment program has been in place since 2012, funded with a federal grant from the National Health Service Corps branch that requires a dollar-for-dollar match. For the last three years, the Legislature has been the primary funding source of the match, but can no longer afford it, said Withy.
To date the program has funded 52 loan re-payers. “Of our graduates, 57% stay where they did their service, which is twice as many as for the National Health Service Corps program. This year, there is no money for the State Legislature to fund the program, so we have been provided with temporary funds from University Health Alliance, Hawaii State Rural Health Association, Mayors of Big Island and Maui, Hawaii State Rural Health Association and Department of Health Office of Primary Care and Rural Health,” said Dr. Withy.
Seiji Yamada, MD, MPH is a family physician practicing in Hawaii. He said, “While loan repayment programs help ameliorate this situation somewhat – what is needed is an overhaul of health care financing to compensate primary care more fairly.”
Possible Solution #2 Recruit Foreign Physicians
The Hawaii State Office of Primary Care and Rural Health has a program to get foreign physicians to work in Hawaii in need areas. It’s called the Hawaii State Conrad 30, J-1 Visa Waiver Program.
How it works? Foreign physicians must commit to serving for 3 years in an underserved area of Hawaii, waiving the foreign medical residency requirement and allowing them to remain in the US. Areas of eligibility include primary care physicians, psychiatrists, and sub-specialty trained physicians. Applicants to the program must first attain a J-1 Visa waiver through the US Department of State then secure an employment contract with a medical facility in a Medically Underserved Area.
Accepting more foreigners to the University of Hawaii Residency Programs could also help with the physician shortage. Dr. Sonido said the University must open more slots to international medical graduates. “They have historically provided care in the inner cities and the healthcare centers serving mostly the underserved.”
Resident physicians receive hands-on medical training and offer assistance to medical staff, which could be invaluable in times where there is a physician shortage.
Possible Solution #3 Active Recruitment and incentivizing Hawaii medical graduates to return to the state
Led by Dr. Aurora Mariani, the HFH (comprised of over 70 physicians mostly in primary care) actively recruits physicians to come to Hawaii with incentives and support for practice management.
Dr. Sonido said at PCCH “we have made it a priority to recruit our previous medical students and trainees to come back to Hawaii. This coming July, for example, an endocrinologist and a family physician will join us.” Currently, PCCH employs 9 physicians and 2 APRNs distributed over three islands.
Hawaii Health Workforce Summit is another recruitment effort. Dr. Withy said they work with Hawaii graduates and Hawaii license holders to bring them back to Hawaii. The Summit brings together providers from across Hawaii. “We have between 500-600 participants who learn of medical updates and get to network. This year we had 535 participants on a virtual platform. We advertise all available positions on ahec.hawaii.edu/doctor-jobs/ and work with recruiters to promote Hawaii careers and get interested applicants to interview.”
Another recruitment effort is being launched by the Physician Workforce Assessment Project that plans to hire a Hawaii physician recruiter to work closely with the Hawaii Physician Recruiter Group to match program graduates and interested physicians with open positions. The recruiter will also assist with finding young doctors to take over practices of retiring physicians; and setting up physician connection groups on all islands.
Effective in 2019, a preceptor tax credit became available to those offering professional instruction, training, and supervision to students and residents in medicine, nursing and pharmacy. Currently, 225 physicians have qualified for the credit and more will be reviewed.
The group is also working to assist in the development of John A. Burns School of Medicine scholarships that require pay back of time practicing in Hawaii.
Reason #3: Physicians are moving away, cost of living and operating solo practice are too high
Possible Solution #1 Provide Housing Stipend
The high cost of living is one of the reasons why physicians are leaving Hawaii. Housing stipends to qualified physicians is something that could incentivize physicians to practice in the islands, health experts say.
Possible Solution #2 Get Rid of GE Tax on Health Services
In the 2020 Hawaii Legislature, there was a bill introduced but cut short due to COVID-19 that sought to exempt health care services provided by doctors and primary care APRNs from the general excise tax.
Hawaii is only one of two states that taxes health care services, and the only state that taxes Medicare benefits.
Eliminating the GE Tax could help physicians in private practice who are struggling to stay afloat, experts say, but the State’s budget shortfall might suspend efforts for the bill’s passage in the near future.
*Possible Solution #3 Increase local insurance reimbursement and raise Medicare and Medicaid reimbursement
Dr. Waite said it’s well known that fee for service and per member per month insurance payment in Hawaii lags behind mainland fee schedule. “What a shame. How can we attract doctors to come and practice if the ‘grass is greener somewhere else’?”
Dr. Sonido said, “Insurance companies have to pay the providers close to their counterparts on the mainland to keep them here.”
Dr. Withy agrees, “We must increase reimbursement to physicians. Small practices cannot survive without higher pay and no new physicians are going to move here without higher reimbursement because of our cost of living being so high. We were the 50th worst state to practice medicine in last year according to Medical Economics. This is terrible! Why would anyone move here unless their family and friends were all here?”
Last year, Hawaii’s congressional delegation signed a letter to the Centers for Medicare and Medicaid Services asking it to look at the geographic adjustment, which is readjusted every three years. Other states, such as Alaska, have been successful in securing increased reimbursement rates.
Lt. Gov. Green said it’s not likely that there will be increases in reimbursements or tax cuts for Medicare-Medicaid during a pandemic driven recession.
Reason #4: The State lacks enough residency training positions
Possible Solution – Expand UH Training Program
Dr. Withy said training local students is the best way to create and keep Hawaii’s future physician workforce. To accommodate many of the University of Hawaii’s medical graduates, health experts recommend expanding UH’s training program or else many resident physicians will continue to leave the State.
This 2021 Legislature, a bill (S.B. 846) was introduced to provide additional long-term funding to Hawaii’s teaching hospitals to support and expand their residency training programs. The Department of Health is working with a Medical Education Council on this bill.
Dr. Yamada said because the UH School of Medicine does not have its own hospital or clinic system, it must work with the hospitals, clinics and individual physicians in the community to provide its students with sufficient clinical experiences.
Even if the UH Medical school expands class size, it also means the school must seek more physicians in the community to volunteer to teach its students.
“Unfortunately, with physicians’ work lives dominated by EHRs and administrative requirements – it is difficult for them to teach medical students in their offices. They are thus often less accepting of the responsibility of teaching medical students,” said Dr. Yamada.
Reason #5: UH Medical School is too small
Possible Solution – Increase size of UH Medical School
There are talks of increasing the size of the medical school and adding medical school branches on all islands, as well as residency programs. Cost is the main obstacle.
Dr. Withy said, “If we could triple the size of the medical school and the residencies, that would be a long-term solution. We have increased to 77 students a year and had a plan to start a satellite campus on Maui for an additional 10 students a year that was not funded because of COVID. We hope to return to that idea as soon as our economy is stable,” she said.
Lt. Gov. Green said “The medical school is one of the best in the country and is growing slowly. It is only able to grow in small increments because there aren’t a surplus of funds to hire more professors.”
Reason #6: There are too many administrative requirements for physicians
Possible Solution – Decrease paperwork burden.
Physicians, especially those close to retiring age, complain about the added administrative requirements. Some have decided on early retirement and closed their practices because of overburdening administrative rules.
“Physicians are encumbered by all the hoops that they must jump through to care for their patients. Each insurance company has its own formulary, and there is no way for physicians to remember which medications are covered by any particular insurance company. “Prior authorization is required non-formulary medications as well as for many diagnostics such as advanced imaging. There are just not enough hours in the day to complete prior authorization forms or speak on the telephone with insurance representatives for all that patients require. Many physicians thus resort to prescribing generic medications and completing prior authorizations for only the most dire patient circumstances,” said Dr. Yamada.
He said increased documentation requirements for reimbursements means that physicians spend more and more time at the computer, clicking through electronic health records (EHR).
A study published in the Annals of Internal Medicine journal found ambulatory care physicians were with patients for only 27% of the day, while they spent 49% of the day on EHR and desk work. They also spent 1-2 hours in the evening on EHRs.
Hawaii psychiatrist, Dr. Stephen Kemble, said elimination of pay-for-documentation would help restore professional autonomy and morale.
Dr. Waite points out that bureaucratic paperwork also leads to physician burn out, adding “let doctors do the doctoring and not paper working.”
The reasoning for EHRs or proper medical record keeping is to protect doctors from lawsuits by reducing risk management exposure and to ensure better patient care. It also must be done to ensure appropriate reimbursement.
David Thompson, MD and chief medical information officer of SCP Health said “Medical reimbursement is reflective of what you document, not what you do. I can take care of a patient with a wrist fracture, pneumonia, or a myocardial infarction, but if there is no documentation, there is no reimbursement.”
Health management that includes managing an increasingly larger staff and complying with and making sense of all the required documentation is a business of itself within the business of practicing medicine.
Lt. Gov. Green said, “The insurance companies have worked closely with the physician organizations on admin simplification and payment transformation. For some this has been a great success, others are frustrated that there is any need to work with insurers. There needs to be a partnership for better care for our people.”
While there are collective efforts to address Hawaii’s physician shortage, by the state and federal government, the UH Medical School and physicians groups, the clock is ticking as the older generation of physicians retire and too few younger physicians are stepping up and stepping in to take their place. Time is running out.