Whenever I travel, I like to look around to assess what it might be like to give care or receive care in the places that I visit. As I write this post, I am flying home from eleven days in Hawaii, where unlike most of the tourists, I was checking out where doctor’s offices could be found, noticing the number of urgent care outlets, and seeing if I could see what the hospitals looked like and where they were located. In Hawaii you do not need to travel far for the scenery to change dramatically, nor do you need to travel far from Honolulu to move into a world of healthcare that shares many similarities with some of our most disadvantaged urban and rural locations on the mainland. 

 

Part of my interest in Hawaiian healthcare stems from the fact that in 1969 my wife worked as a nurse at The Queen’s Medical Center in Honolulu, and over the years she has described to me many of her experiences working with one of the most diverse populations of patients in the world. On my first visit to Hawaii in 2007, we visited Queen’s. It had changed a lot, but there were still a few of her old colleagues working there, and we contacted some others who were then working at the Kaiser Permanente Moanalua Medical Center. This time around I was coming from the perspective of a dozen years of intense interest in the future of healthcare in America. I have a persistent obsession with how we might best address some of our most persistent and vexing challenges. 

 

Hawaii has been a leader in the push toward universal coverage. In 1974 Hawaii took a very progressive step by passing what is called the Hawaii Prepaid Health Care Act. The law established minimum benefit standards for policies, and required employers to provide health insurance for all employees who worked at least 20 hours. At the time, there was fear that some employers would “game the system” by limiting working hours, especially in industries like tourism which employs many Hawaiians who work in the hotels and restaurants of the many resorts, shops, tourist attractions, scenic venues, and recreational activities. 

 

I asked a veteran bartender and waiter at a restaurant in Poipu, a very touristy and upscale area of Kauai, about his healthcare experience because my bill for that meal included a 4% “healthcare tax” which I had not seen on other restaurant checks.  He was a man who was “born and raised” on Kauai. He said that as far as he was concerned, the system has worked very well. He has been employed in several restaurants, and in a few different industries, including construction, and his employers have always treated him fairly providing him with the healthcare coverage that he needs. The best testimony to the long term efficacy of the 1974 act is the fact that for years Hawaii has had one of the lowest rates of uninsured citizens in the country. Hawaii’s high scores in coverage for access exist despite other significant problems which I discovered when I began to look around. The biggest issue facing Hawaii is a healthcare workforce shortage. Every island has compromised access to primary care, and there are widespread shortages of critical specialists. 

 

A recent article from one of of the papers from the “big island” describes the current challenge in an article entitled “Why the Doctor Shortage Continues in Hawaii.” Hawaii has only one  medical school, the John A. Burns School of Medicine at the University of Hawaii on Oahu. JABSOM has graduated about 4000 doctors from the medical school and affiliated residency programs since it was launched in the mid sixties. A majority of Hawaii’s practicing physicians were trained in one of its programs. Over the last several years the class sizes have increased in response to the shortage of physicians, but the medical school still had only 77 graduates in 2019 and enrolled a similar number of students this fall. Each year there are residency slots in training programs at hospitals across Hawaii affiliated with JABSOM that are unfilled. The shortage of trainees in the system is a big problem because data shows that residents tend to develop both professional and personal relationships where they train, and a significant number stay in the area where they trained. The author of the article, Sierra Hägg is specific:

 

Comparing the number of physicians that the Big Island has to the average utilization of physicians across the United States, Hawai‘i Island comes up short with 41% fewer physicians than the island should have, making it commonplace to wait four to five months for a primary care or specialist physician.

Statewide, Hawai‘i is short approximately 800 doctors.

The problem is expected to escalate because many of the state’s doctors now are near retirement and there aren’t enough incoming doctors to take their places. The State of Hawai‘i currently has 600 physicians 65 or older.

In addition, many doctors are leaving the islands. From 2017 to 2018, the state lost 51 full-time-equivalent doctors. In fact, Hawai‘i was found to be the third worst state in which to practice medicine due to low wages and a high cost of living. Experts say a net gain of 650 doctors is needed in the state by 2020.

 

The problem is not limited to primary care:

 

East Hawai‘i [around Hilo on the big island] has a projected population of around 117,000 by 2020. To serve that population, there are four general surgeons (one of whom is near retirement), three orthopedic surgeons, three gastroenterologists (two of whom are past retirement age) two cardiologists and two nephrologists.

The entire island has a projected population of around 217,718 by 2020. Serving the entire island are one urologist, one neurologist and one permanent ear, nose and throat specialist.

 

The crisis in the healthcare workforce has not gone without attention. Mike Brigoli, MD, is one of seven students from “the big island” who graduated from JABSOM in 2019. He is leaving for a residency program at the University of Arizona. He understands the problem, and although he is leaving, advocates for more training opportunities within the state.

 

“Regarding how the state can get more medical graduates to practice locally, that data has been proven through research by Dr. Kelley Withy: increasing the number of people training here will increase the number of physician working here,” said Dr. Brigoli. “Whether that’s increasing the number of students in medical school or increasing the number of post-graduation residency positions, both will lead to more physicians staying in Hawai‘i.”

Dr. Brigoli felt where graduates took their residency was a primary determinant in where they would end up practicing.

“People develop relationships, bonds while training,” said Dr. Brigoli. “They get married, have children and learn [the] culture [of] our society. It’s a unique time. There are medical specialties that we still do not have residencies for in Hawai‘i, like emergency medicine for example.”

 

The article also quotes the dean at the John A. Burns School of Medicine. The dean laments that state money for expanded healthcare education is scarce. Currently there are 184 full time and 241 part time faculty members. He needs more funding to hire more faculty to support a larger student body.

 

“We have been advocating for increasing the number of students admitted to JABSOM for over a decade. Through medical school restructuring, growth of an affiliated practice plan and partnering with local healthcare systems, JABSOM has gradually increased the number of students, from 62 to 77 [this July], in the entering [matriculating] student cohort. This growth has occurred in the setting of an essentially flat UH base budget for JABSOM.

“Additional state support is greatly needed to increase the number of UH teaching faculty and staff [and to expand teaching facilities] essential for an even larger class size,” said the dean. “Additional support could be used to extend more medical education to the Neighbor Islands. With this limited state support, JABSOM post-graduate residency positions have remained largely flat. Although many factors contribute to limited expansion of the medical school class and residency positions in Hawai‘i, the primary factor is a limited number of compensated clinical faculty. Support for clinical faculty could not only help expand class size, but also help bring needed practitioners to Hawai‘i.”

 

When searching for the answer to Hawaii’s doctor shortage we need to look both inside the state and across the country. The analysis for Hawaii is somewhat unique, but it also shares some similarities with rural and urban areas on the mainland that are having a similar experience. A 2018 article about Hawaii’s specific problems published in another local paper and entitled “Study: Hawaii’s physicians shortage got worse in 2018” makes the following observations:

 

• From 2017 to 2108 the islands lost 51 full-time equivalent doctors..
• As of 2018 Hawaii was 750 doctors ( 22% below optimal stagfing) short of what’s needed across all specialties.
• The Big Island had the most severe shortage — at 41 percent. In Maui County and Kauai, the figure was about 33 percent. Oahu was short 384 doctors or about 17 percent.

 

Dr. Kelley Withy at JABSOM identified the following explanations

 

• Older doctors are opting to retire because of more complex insurance payment systems and requirements.
• Young to mid-career doctors are leaving the islands because salaries are low when compared Hawaii’s high cost of living.

 

Hawaii is a great place to visit on vacation, but a recent study showed that because of low wages and “a lack of opportunity” it was the third worst state in the nation to practice medicine. 

 

Leadership in the state is trying to improve the situation by offering tax credits and loan repayment programs to entice young physicians to the state. The physician shortage is not the only workforce concern. Hawaii has other healthcare professional shortages. They also need nurses, physicians’ assistants and psychologists.

 

The picture in the header for today’s post is of the critical care hospital and medical office building in Waimea, on the less populated western side of Kauai. Waimea, with a population of a little less than 2000, reminded me of many of the small towns in America. Waimea is a little town with a very interesting history.  Waimea is where Captain Cook, and the first Europeans landed in 1778. It has a lot of history, but I am not sure that it has a rosy future. It is across the island and on the periphery of the tourism. It does not look like it is a part of the intense development on the eastern and northern parts of Kauai. Gone are the days when Waimea was an important trading post for the whaling and sandalwood industries.  The sugar industry of the 1800s is gone. 

 

These days Waimea is a sleepy little town with a lot of poverty trying to make it on construction and tourism. I would guess that the Kauai Veterans Memorial Hospital, like the critical access hospital in my little town, is one of the largest employers in the area. Many of the 25 or so hospitals in Hawaii are probably similar to Kauai Veterans Memorial in the challenges they face from their location in poorer communities where it is difficult to attract staff. 

 

A follow up article to the 2018 discussion of staffing shortages published this September was entitled “Hawaii’s doctor shortage is taking ‘a troubling turn for the worse.’” The article did not have much progress to report despite the recent efforts that have been made to fill the gaps in the healthcare workforce. The headcount is down another 108 over the past year. Hawaii still needs 600-800 physicians and over 25% of its doctors are retirement age. What was more upsetting to the authors was that 39 more physicians just left Hawaii, presumably for better jobs elsewhere.

 

I know from my work on the board of the Guthrie Clinic, a very successful healthcare system in the rural and small town environment of the “twin tiers” of south central New York and north central Pennsylvania, that a shortage of healthcare professionals, doctors of all types, but especially PCP’s, nurses, NPs, and PAs, is our biggest challenge. Doctor shortages are not unique to the less populated Hawaiian islands. Healthcare finance everywhere is complicated by the need to use more money to cover short term needs with traveling nurses and doctors working as locum tenens, while trying to invest in ways that enable the hiring and retention of permanent staff. Hospitals and practices in rural and small town America must offer either money or an unique opportunity to be able to compete for staff with medical systems in more populated urban areas. 

 

Just a couple of months ago, CNBC broadcasted a program and published an article describing the doctor shortage across America.  I think the reasons for our workforce shortages, as the situation in Hawaii demonstrates, are much more complex than their title, “America’s aging population is leading to a doctor shortage crisis,” suggests. They do begin by offering “Key Points”:

 

• As America’s population ages and demand outpaces supply, a physician shortage will intensify.

• The U.S. is expected to see a shortage of 46,900 to 121,900 physicians by 2032 in primary and specialty care.

• Americans are living longer and requiring more care later into life, and doctors themselves are aging out of the profession.

 

They elaborate:

 

Projections from the Association of American Medical Colleges say the U.S. will see a shortage of 46,900 to 121,900 physicians by 2032 in primary and specialty care…What’s more, one-third of all doctors currently working will be older than 65 in the next decade, and retirements may squeeze supply.

 

The article discusses the specific issues in Arizona, not a bastion of progressive politics. Arizona’s has a large and growing over 65 population. It ranks 44th among states in the ratio of PCPs to 100,000 people at about 77. The article suggests the optimum ratio is about 91 doctors per 100,000 patients. Arizona hopes to attract physicians and nurses by changing licensing regulations, moving to more team based care, and improving residency programs to attract more doctors in training. The strategy will require greater state and federal funding in a state where taxes and the federal government have traditionally been unpopular.

 

None of these points are news to me, and I doubt that they are news to you. I have suggested on many occasions that our current concerns about healthcare finance are quickly becoming secondary to our worries about “workforce.” The two issues are very connected. Workforce shortages induce further financial losses and have the potential to undermine much of our work to improve quality and safety while lowering the cost of care. I have said, and will say again, that the most urgent reason we need to redesign care delivery is that we can no longer provide enough healthcare professionals to care to the entire population using our current practice methodologies. I have worried about this issue for at least the last fifteen years, if not longer, as I witnessed the growing problems with staffing in the organizations that I served, either as part of the governance or in management. 

 

I think the issue is like global warming. We have known the disasters of climate change were coming for a long time, and yet we have not prepared adequately for the challenges that are now upon us. You don’t have to go to Hawaii to see the problem with the doctor shortage in this country. Go to almost any small town or into “the less desirable neighborhoods” of our cities. Go to those places where your life expectancy is a ZIP code related phenomena. Go to those neighborhoods that you try to avoid when driving, and that have often been “gerrymandered” out of having much political representation, or where voters face such discouraging barriers that they elect not to exercise their franchise to vote because it will cost them time away from work in long lines before they are challenged by the election officials. 

 

Just like we are suddenly seeing violent weather with temperatures and consequences accumulating faster than we expected, if we know where to look, workforce shortages are happening faster than we can manage, and in ways that will affect the heath of many millions of Americans before we know it. I would put the healthcare workforce problems in many “red states” and some that are just poor, as a greater concern than the obvious ones in Hawaii where there is at least an ongoing conversation and a history of progressive efforts to improve the health of the population. In Hawaii there are real efforts being made to address workforce issues. 

 

We know the things that we could be doing. In 2010 as the ACA was being passed, Thomas Bodenheimer and Hoangmai H. Pham, published “Primary Care: Current Problems And Proposed Solutions” in HealthAffairs. The article is a classic that deserves a reread by anyone who cares about workforce shortages, especially in Primary Care. Its predictions are coming true faster than most people care to admit. Its suggestions have been implemented by a fraction of our health systems. Here is their conclusion:

 

The United States has a serious geographic maldistribution of primary care services and is entering an era of primary care workforce shortages. Improving access to primary care will require major macro-level system reform—in particular, increases in primary care reimbursement both to reduce the primary care–specialty income gap and to invest in primary care practice improvement. However, even with a primary care practitioner shortage, many micro-level system adjustments could improve patients’ ability to obtain prompt primary care services. These could include adding evening and weekend hours, instituting open-access scheduling, increasing the return-visit interval, using e-visits and phone visits, and delegating important but routine functions to nonprofessional staff.

The primary care renewal policy agenda, then, is multifaceted. It is a critical element of any health reform aiming to expand insurance coverage while reducing costs. Coverage expansion and the resultant demand for primary care access presents an opportunity for policy makers to legislate substantial and long-term investments in the primary care infrastructure.

 

We all know that much of the necessary policy implementation needed to derive the greatest benefit from the ACA as conceptualized has been delayed by continued resistance in the courts. Many “red states” have refused to expand Medicaid, or agreed to do it only after trying to attach work requirements and other burdensome regulations. We have been debating the need to change while many of our problems have been growing to the point that solutions seem unlikely within what we are willing to change. In some rural areas, and in areas of urban decline, it is hard to imagine how we will ever improve the health of the citizens that live there without enormous efforts that so far seem unlikely. We now just shrug our shoulders and say, “Isn’t it interesting that a person’s life expectancy is more a function of their ZIP code than their genetic code?”

 

If Hawaii needs to add a tax to my restaurant bill, or use some other mechanism to take advantage of my visit to generate the revenue to improve the health of the community by improving its healthcare workforce, I am all for it.