Here in East Hawaii, the Titanic has already hit the iceberg. Lifeboats are in the water filled with stunned and freezing survivors while the majority of those left on board stare into the abyss hoping someone’s coming to save them.

Hope is fading. Fast.

Residents of East Hawaii needing a medical specialist’s care know that they are 1) waiting a long time, 2) driving to Kona because most don’t practice in Hilo, or 3) flying to Honolulu or the mainland because health services here are a joke. But it’s no laughing matter.

Short version: There are very few medical specialists on the outer islands, fewer still on the Big Island, and least of all in East Hawaii (per capita).

But of greater and more immediate concern is the alarming shortage of primary care physicians — PCPs — here in East Hawaii. They are those trained for and skilled in comprehensive first contact and continuing chronic care. They are your first call, the front line in preventative medical care for you and your family, and their shortage has exceeded crisis proportions, and worsens by the day.

A rural road in vast Puna, where medical care can be hard to come by.

Flickr: Frank

My story, briefly:

I live in the Puna district of the Big Island, which by geographic position alone places my access to quality primary health care at the very bottom statewide. And if one is fortunate enough to be seen by a PCP at all, then any referrals to other services or specialists becomes a scheduling ordeal.

I moved to the Big Island 4.5 years ago from Minnesota — the land of health care excess! During that time, I have been shuffled from one PCP to another. At Kaiser Permanente in Hilo (a 30-minute drive one-way), I saw three different PCPs during an 18-month period. They were all reasonably young, and they all moved away seeking greener pastures.

A change of employer caused a change of insurance, and I found myself at the Bay Clinics of Keaau and Pahoa. Two of my PCPs retired, and two more moved away, due ostensibly to financial difficulties. My last Bay Clinic PCP only saw patients on Fridays, so it literally took months to schedule an appointment. My final two visits there were with a physician’s assistant, so now I see a private PCP in Hilo that is so overburdened he failed to update my current medications or review my last lab results with me (high potassium, low iron, borderline diabetes).

I would add that in that time, not one of eight PCPs I have seen here ever detected my atrial fibrillation. Thankfully, my partner (also a doctor) noticed it last spring, and I now have a life-saving pacemaker. And even then, I had three separate cardiologists in one year, two failed cardioversion procedures by two separate cardiologists, a pacemaker implant, and follow-ups by two separate cardiologists — none of whom practice full-time on the Big Island.

Third World Health Care

Referrals to specialists are invariably off island or on the Kona side. I have made three trips to Honolulu to see specialists and have driven across the island more times than I can recall because such services are unavailable to us here in East Hawaii. Third World health care in the world’s wealthiest country! Appalling, and a statewide embarrassment.

There are admittedly multiple factors at play here: cost of living, lifestyle, recruitment and retention of PCPs, for example. But the biggest culprit by far? Unconscionably low compensation to PCPs on the part of the state’s biggest health insurer, HMSA. We must start by finding a way to fairly and immediately compensate those few remaining PCPs here in East Hawaii to avoid the medical catastrophe that will surely ensue by their imminent departure.

Perseverance. These PCPs desperately want to be here, to remain in Hawaii serving their patients and their communities. But they are heavily overburdened, overworked, stressed, burned out, and at the breaking point economically. HMSA’s inadequate primary care physician compensation structure inevitably leads to one private practice failure after another, jeopardizing the health and well-being of each PCP’s entire patient panel along with it.

We are rapidly approaching the point where the vast majority of East Hawaii residents will still have adequate health insurance in some form, but no primary care physicians left to see!

According to the National Conference of State Legislatures, the average annual premium for single coverage health premiums rose 3 percent in 2018 to $6,896. That’s an average of $575 per patient per month!

And yet, as Dr. Michelle Mitchell, president of Hawaii Family Health, wrote in a recent op-ed in the Hilo Tribune-Herald”

HMSA’s capitated payment transformation (only) pays PCPs an average of $24 per patient per month. Studies show that high quality, comprehensive primary care requires reimbursement of $45-$64 per patient per month — twice the rate of reimbursement from HMSA. And HMSA’s fee for service reimbursements (alternative to payment transformation) have not changed significantly since 2008, while minimum wage has increased 39 percent. With these substandard reimbursements, it is impossible for a physician’s practice to remain financially viable here in Hawaii.

It’s a perfect storm. Doctors cannot organize, collectively bargain or go out on strike. They simply have to accept what the insurance companies decide to give them. Think of it: out of a $575 monthly premium, your PCP receives a paltry $24 per month to keep you alive! Clinics are closings, businesses are failing. Doctors are retiring or burning out or moving away. And who is coming to replace them?

Hope is fading fast.

House Bill 1464 is making its way through the Legislature, requiring a state investigation into HMSA’s woeful payment practices to physicians. Hardly a panacea, but perhaps a start? But then again, I can well imagine that with HMSA’s vast resources and army of lobbyists, even this half-measure could easily die a quiet, painless death, not unlike so many well-insured policy holders that cannot find a health care provider.

As Lord Tyrion Lannister from “Game of Thrones” said, “The powerful have always preyed upon the powerless.”

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