Editor’s note: This is the first of a two-part series examining the shortage of mental health care in Hawaii. It’s part of an ongoing initiative to look more closely at problems faced by the people with mental illnesses here and possible solutions. 

When Stephen Kemble closed his Honolulu psychiatry practice last August, he tried to match 500 patients with a new psychiatrist.

It was an impossible task — especially for recipients of Med-QUEST, Hawaii’s version of Medicaid.

Kemble found only two psychiatrists in private practice on Oahu who were willing to treat new patients covered by the state’s public health insurance for low-income people. A few of Kemble’s patients got in with these two psychiatrists — but they had to wait up to three months for an appointment, he said.

“The willingness of psychiatrists to take in new Medicaid patients has dwindled to almost nothing,” Kemble said. “Even if you do get in with someone, the doctor has five minutes to renew your prescription and that’s it. I mean, they’re trying, but the psychiatrists don’t even have time to talk to you — they’re totally overwhelmed.”

New data from the University of Hawaii reveals a health system in crisis. In 2017, Hawaii was short more than 750 physicians across the medical field, according to University of Hawaii professor Kelley Withy, who conducts an annual workforce survey. This calculation accounts for differing needs on neighbor islands and the unique demand for medical specialties like psychiatry.

Experts say filling the void is practically impossible, as it would require that the state increase its physician workforce by about 25 percent. Luring new doctors to Hawaii is complicated by myriad factors, not the least of which is the state’s high cost of living coupled with its relatively low rates for insurance reimbursement.

When it comes to psychiatrists, the UH data reveals a 10 percent statewide shortage. The gravest scarcity is on Kauai and Hawaii islands, which are tied with a whopping 33 percent shortage.

But surprisingly, the Oahu data shows a slight surplus equivalent to one full-time position.

Withy acknowledges the Oahu numbers, which are based on the national statistics, fly in the face of what she sees first hand: a severe need for psychiatric services that’s not being met — on any island.

“I don’t think our model adequately represents the demand in Hawaii,” Withy said. “Perhaps people in Hawaii are more open to using behavioral health or need more services, but the model does not correspond to the anecdotal need we hear about. Also, many psychiatrists don’t take our public insurance programs, making it extra hard for those individuals, who usually need the services even more due to poverty or disability, to find services.”

Withy’s workforce data does not expound upon this second point: the statewide shortage is particularly pronounced for people with public health insurance.

Med-QUEST provides insurance coverage for a quarter of Hawaii’s population, including half of all births. Yet a half-dozen psychiatrists interviewed for this story said private practice psychiatry is increasingly averse to accepting public health insurance due to reasons including burdensome regulations and low rates of reimbursement — sometimes so low as to barely cover the cost of care.

A psychiatrist who treats a Med-QUEST patient can receive as little as two-thirds of the reimbursement rate paid by commercial insurers, Kemble said.

Psychiatrists interviewed for this story also reported a widespread unwillingness among their colleagues to accept Medicare, the federal health insurer for people 65 and older, as well as younger people with disabilities. Roughly 17 percent of Hawaii residents receive health insurance from Medicare.

“With Medicaid and Medicare, there’s too much red tape involved. The paperwork can be overwhelming.” — Psychiatrist Greg Yuen

“My personal experience is that people that have resources to pay out-of-pocket or people with the ‘good insurance’ don’t have as much of a problem getting an appointment with a psychiatrist, even though there’s a shortage,” said Sonia Patel, a Honolulu child and adolescent psychiatrist. “The problem comes with people and families that don’t have as many financial or social resources. People with less resources tend to be steered less toward psychiatric care and more toward criminal justice.”

Not only can it be more difficult for people with public health insurance to obtain treatment from a psychiatrist, but the prevalence and the intensity of mental health needs in the Med-QUEST population is greater than that of the general population, according to Hawaii Medicaid Director Judy Mohr Peterson.

In Hawaii, people with some of the highest need for psychiatric treatment have a harder time getting it.

“In the past, I was just opening my doors to everyone,” said Honolulu psychiatrist Greg Yuen, who teaches free Tai chi classes as a supplement to his psychiatry services. “But now I’m near retirement and I’ve put in my dues to help the community. I am only taking commercial insurance because the pay is higher and the patients are a little more reliable in terms of showing up for an appointment. With Medicaid and Medicare, there’s too much red tape involved. The paperwork can be overwhelming.”

An office manager at an Oahu psychiatry office — one of the two practices Kemble identified last year as willing to accept new patients with public insurance plans — said the doctor leading the practice continues to accept Med-QUEST and Medicare because those patients have almost nowhere else to turn for treatment.

The office manager did not want her name, nor the name of the psychiatrist by whom she’s employed, published in this story.

She said she doesn’t wish to invite a deluge of desperate calls for appointments. The practice is already struggling to meet the needs of its established patients.

In the end, Kemble arranged for many of his patients to refill their prescriptions for psychiatric medications with their primary care doctor. He simply couldn’t find enough psychiatrists to take them on.

Greater Need, Fewer Options

Although the state’s psychiatrist shortage is not an issue specific to Med-QUEST, Peterson, the state’s Medicaid director, acknowledged that people with public insurance tend to wrestle with the issue of access to psychiatric treatment more than the general population. That’s because Med-QUEST recipients have higher mental illness prevalence rates and therefore are more likely to need a psychiatrist’s services.

Under Med-QUEST, health services are provided through five managed care plans. One of them, Ohana Health Plan, has a specialized program called Community Care Services that offers recovery-focused behavioral health treatment to 5,000 Medicaid-eligible adults diagnosed with a serious mental illness.

Ohana Health Plan’s menu of services for these people includes face-to-face case management, around-the-clock crisis assistance and connections to social support programs, such as housing, food or employment. Enrollees can receive assistance in maintaining their health insurance, food stamps or personal finances.

These programs are crucial for people who experience symptoms that can interfere with their ability to maintain stable housing, engage in work or social activities or maintain a regimen of healthcare treatment, said Maria Miles, an Ohana Health Plan spokesperson.

Miles identified the documented shortage of physicians, the fragmentation between physical and behavioral health and the local housing shortage as the top challenges to health care in Hawaii.

For people on Med-QUEST with mild to moderate mental illness, a visit to a psychiatrist’s office is covered by their insurance plan. But when there’s no psychiatrist available, some Med-QUEST recipients turn to their primary care physician. 

General practitioners can prescribe psychotropic drugs, which can have serious side-effects. But they may not be qualified to make a correct diagnosis. They also may not understand how the chemistry of a psychotropic drug interacts with other medications. 

Research suggests most patients receive better care from a psychiatric specialist than a family doctor when seeking treatment for depression.

“The problem with the psychiatric patient is he’s going to jam up your whole schedule,” said Jeffrey Akaka, a Honolulu psychiatrist and mental health policy advocate. “When you’re a psychiatrist, your schedule is set to see one patient every hour. But for primary care doctors who are under the gun to see an assembly line of patients, they just don’t have time to hear your whole story. They can’t give you an hour — maybe they can give you a few minutes.”

New measures aimed at boosting primary care doctors’ comfort with treating mental illness are sprouting across Hawaii. There’s a free webinar that schools primary care doctors on behavioral health treatment and a new substance abuse screening tool.

Some doctors are joining new models that emphasize mind and body health care integration. Others are delivering care through the internet, boosting the statewide use of long-distance telehealth from 2 percent in 2014 to almost 21 percent in 2018, according to UH data.

By arming general practitioners with the tools to treat mild to moderate mental illness themselves, the hope is that the state’s psychiatrists will be freed up to focus on more acute patients.

‘People Deserve Better’

Another barrier to mental health care access is Hawaii’s rural island geography. There is no psychiatrist on Molokai, and the Big Island is so short on mental health resources that several Honolulu psychiatrists routinely fly to Hilo in an attempt to close the gap in access to treatment.

Youth on the Big Island who experience a mental health crisis typically must fly to Oahu for treatment. But when all of the state’s psychiatric beds are full, which happens from time to time, there’s no place for these neighbor island patients to go.

Even in Honolulu, where most of the state’s psychiatry offices are concentrated, patient need at times outpaces practitioner availability.

Big Island emergency room doctor Josh Green treated a 16-year-old patient earlier this year who arrived at the ER because she attempted suicide.

The girl was off her psychiatric medication. She required overnight monitoring. But there were no psychiatric hospital beds available that night — not on Oahu, not anywhere in the state.

“A suicide attempt is a serious situation and people deserve better.” — ER Dr. Josh Green

So Green, a state senator who just won the Democratic nomination for lieutenant governor, rolled a cot outside the door to the patient’s room at the ER and kept watch until morning.

The scenario exposes the fragility of Hawaii’s mental health system — a product of a severe shortage of treatment programs and professionals.

Access to psychiatric care is especially bleak on neighbor islands, where insurers will cover costs associated with flying patients to Oahu for treatment. But when the beds in urban Hawaii fill up, physicians are sometimes forced to invent on-the-fly solutions.

“A suicide attempt is a serious situation and people deserve better than me sleeping outside their door in our little four-room ER,” Green said. “This can’t be the model.”

‘I Don’t Want To Just Serve Rich People’

It’s unreasonable to think Hawaii will ever be able to hire enough psychiatrists, Peterson said.

An increasing number of students are pursuing the field of psychiatry, but patient demand for psychiatric services is exploding at a faster rate.

Hawaii’s primary psychiatry school at the University of Hawaii’s John A. Burns School of Medicine has 70 psychiatry students enrolled in the 2018 freshman class. This marks a slight increase from years prior.

“I don’t want to just serve rich people. But there is that balance. I have to see all levels of people just so that I can pay all of my bills, too.” — Psychiatrist Sonia Patel

JABSOM students decide in their third academic year if they intend to pursue a residency in psychiatry, or shift to some other specialty.

There will be eight psychiatry residents in 2019 — up from five the previous year.

Tripler Army Medical Center hosts a four-year psychiatry program for uniformed services. The program’s average graduating class hovers at six students.

By these numbers, Hawaii can expect 14 new psychiatrists entering the field locally this year — if they choose to stay in Hawaii.

Meanwhile, burnout is high among the local psychiatrist community, leading some practitioners to retire early.

Withy said there’s ample anecdotal evidence that the number of psychiatrists who retire or reduce their practice in a given year far exceeds the number of new psychiatrists entering the field.

At a time when nearly one in five U.S. adults lives with a mental illness, Withy said Hawaii’s problem with access to psychiatric treatment is something everyone should care about.

“You never know when you’re going to end up with depression or substance abuse,” Withy said. “Even a highly functioning individual might get to the point in their life when they get depressed, and they’re going to need services.”

“I would guess that many people in Hawaii have been touched by someone who needs mental health services,” she continued. “I know I have. And because my family has private insurance this person has been able to get services as needed. But as we know, many of the people who need the services the most can’t get those services and end up getting into legal and homeless challenges.”

When Air Travel Is The Only Option

For two years, Sonia Patel traveled from Honolulu to Molokai and back one day a week to provide psychiatric care to public school students. Working as a subcontractor for the Department of Education, Patel earned a flat fee for each student — regardless of their insurance coverage status.

Patel was the students’ only option. Molokai has no practicing psychiatrists.

“The schools were good at identifying kids in need,” said Patel, who specializes in treating trauma, family dysfunction and eating disorders. “That being said, if they were quiet and they weren’t disruptive in school, those are the kids I probably missed. If the school picked up on it then I got to them, but if not then they probably suffered in silence.”

Patel said she stopped treating the students when the program lost funding in 2009. But she continued her weekly Friendly Isle flights, renting an office at Molokai General Hospital to host her patients.

Today Patel practices psychiatry at her Honolulu office only. But her patients include neighbor island youth who travel to see her when they can’t find treatment on their home island. Travel costs for the patient and a guardian are usually covered by insurance providers.

“I don’t mind taking Medicaid because, for me, that’s why I went into medicine,” Patel said. “I don’t want to just serve rich people. But there is that balance. I have to see all levels of people just so that I can pay all of my bills, too.”

Patel said she is troubled to work in a healthcare system where children in crisis are better able to obtain treatment if they are privately insured.

Earlier this year she treated a 6-year-old patient who grew up exposed to her methamphetamine-addicted parents’ psychotic behavior. The little girl, she said, was fortunate in that she had an aunt who took her in, fought for power of attorney and enrolled her in Med-QUEST. The aunt relentlessly called psychiatrist after psychiatrist until she found Patel, who agreed to treat the girl and accept her insurance.  

“Thank gosh for the aunt, who called 10 psychiatrists until she got this kid in, because the girl ended up having severe PTSD,” Patel said.

“It just makes me think about how many kids am I not seeing because they don’t have the aunt who’s relentless and finds a way to get them in?” she continued. “How many aren’t being seen because they don’t have the ‘good’ insurance?”

Coming Tuesday: An innovative program by Queen’s physicians to close some of the gap in access to services

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