As most Hawaii residents stay at home, clinics are closing, hospitals are cutting some services and community health centers are struggling to keep afloat.

The COVID-19 pandemic, which had infected 204 people in Hawaii as of Monday, has already taken a toll on other kinds of health care.  

Dental appointments, for example, are now generally restricted to emergency-only scenarios, according to guidance from the Hawaii Dental Association and the American Dental Association. Hospitals are canceling elective surgeries and clinics are postponing other kinds of in-person visits.

Hana Health CEO Cheryl Vasconcellos said the coronavirus has severely impacted the rural clinic’s business. Courtesy: Hana Health

Gov. David Ige also made an announcement Monday that out-of-state physicians will be allowed to practice in Hawaii if they are legally qualified, with the hope that they’ll supplement Hawaii’s already severe doctor shortage.

But as COVID-19 case numbers rise on the mainland, it’s hard to believe Hawaii will be able to attract more doctors during an emergency that is already drastically affecting health care in states like New York and California.

There’s also a new step clinics have had to adopt: screening patients for COVID-19 before they set foot inside, which takes staffing resources, time, and protective gear. To mitigate the loss of traditional types of health appointments, some hospitals are racing to expand virtual health care options, but not every clinic will have the resources.

Community health centers are taking a large hit, especially because their financial health depends largely on in-person appointments.

“If you think about our health care system, we get paid based on visits,” said Richard Taaffe, the CEO of West Hawaii Community Health Center on the Big Island.

West Hawaii Community Health Center’s visit numbers have fallen by 25%.

“None of us as nonprofits have the cash reserves to sustain a long term effort,” he said. “We are the safety net providers in the community and we want to do our job, but we don’t have the financial reserves.”

Cuts To Services

COVID-19 has already taken a toll on staffing, as some health care workers who have even a presumed exposure via a loved one who has traveled must stay at home for two weeks.

“We’ve had three behavioral health providers who had to self quarantine, so they weren’t able to see patients,” said Taaffe. Delays in test results can extend health care worker absences, too.

State health officials say among the 204 people infected, only a dozen have been hospitalized for COVID-19 ailments. Lt. Gov. Josh Green said Monday six patients are currently in the ICU. But those figures do not account for patients suspected to have COVID-19 and treated with the same isolation precautions.

To prepare and make room for future COVID-19 patients, hospitals are overhauling their normal practices by restricting visitors, postponing non-urgent operations, and adopting virtual services when they can.

Dr. Travis Parker, the emergency room medical director for the Kauai Veterans Memorial Hospital and Samuel Mahelona Memorial Hospital, said a no-visitor policy was one of the first strategies they implemented, especially to protect long-term-care elderly patients.

“It’s tough on families to not be able to go give grandma and grandpa a hug, but we set up teleconferencing so they can still have screen time,” he said.

Other routine operations such as colonoscopies or endoscopies have been canceled, along with non-urgent elective surgeries.

“We’re trying to prepare for more emergent cases, say, appendicitis, a gallbladder that needs to be taken out in an emergency, or a trauma patient,” Parker said.

Kauai Veterans Memorial Hospital doctors and nurses practiced caring for a COVID-19 patient during a simulation. Courtesy: Travis Parker/2020

Hawaii Pacific Health’s four hospitals — Kapiolani Medical Center for Women & Children, Pali Momi Medical Center, Straub Clinic & Hospital, and Wilcox Memorial Hospital — are restricting visitors and postponing elective and non-urgent surgeries.

Earlier this month, the Maternity and Newborn Care Unit at the Kapiolani Medical Center for Women & Children was temporarily closed. Instead of the traditional nursery, healthy infants are cared for in the same room as their mothers, who are limited to very few visitors even during birth.

Hawaii hospital visitation rules vary — some have exceptions for critically ill patients or pediatric patients. Most have strict one-visitor or two-visitor policies.

These kinds of policies are to prevent any community spread of COVID-19 and also help staff preserve protective equipment and supplies, HPH spokeswoman Kristen Bonilla said.

“Reducing elective services frees up our hospital services for those who need it the most, including any ill COVID-19 patients,” Bonilla said. “All of these measures help us to reduce the use of PPE needed to protect our health care workers and reduce the risk of transmission.”

Kaiser Permanente had to take even more drastic action. It temporarily closed seven clinics — on Maui and Kauai, its Kihei Clinic and Waimea Clinic and on Oahu, its Hawaii Kai, Kahuku, Kailua, Kapolei, and Nanaikeola clinics. Doctors and staff were redeployed to larger medical offices, which remain open.

“We understand that some of these changes may be an inconvenience, but for Kaiser Permanente and other health care providers this is a necessary step to slow the spread of COVID-19 and ensure that we continue to have the resources, capacity, and staff available to care for our members and the communities we serve,” the hospital’s executives said in a statement.

Kaiser Permanente temporarily closed seven of its clinics due to COVID-19 but maintains operations at its larger medical offices and hospitals. Cory Lum/Civil Beat/2020

Laura Lott, Kaiser’s communications director, says the hospital has been able to shift 80% of doctors’ appointments and consultations online.

Insurance companies are also pushing patients toward virtual portals.

The Hawaii Medical Service Association added more doctors to its online health network, said Christine Hirasa, HMSA spokeswoman.

HMSA is also allowing customers to get their refills earlier and executives said this month the insurance plan would cover the cost of “medically necessary diagnostic tests related to COVID-19.”

Hits To Community Health Care

Telemedicine has its limitations. Not all clinics will be able to swiftly shift to virtual care.

Hawaii Primary Care Association CEO Robert Hirokawa says health centers, clinics, and independent physicians are all struggling to keep their doors open, especially as it gets harder to acquire personal protective equipment.

“It is a perfect storm of sorts,” Hirokawa said. “They have an increased need to provide care to their communities and keep doors open, while at the same time they don’t have access to protective equipment for the staff and financial resources.”

Hana Health, which is the only health care facility in rural Hana, Maui, has already seen patient visits drop by 80%. But the center isn’t easily able to assist its patients on an online portal.

Kaiser Permanente’s telemedicine phone app also screens patients for coronavirus symptoms. Courtesy: Laura Lott

“In affluent communities there’s much greater access to the technology than we have in rural areas,” said Cheryl Vasconcellos, CEO of Hana Health and Hawaii Primary Care Association board chair. “All of the federally qualified health centers are working in low-income and vulnerable communities where the technology may just not be available.”

“Culturally it’s not as an accepted practice,” she added. “It’s an educational curve that’s not going to happen overnight. Same goes for our kupuna.”

On Oahu, about 40% of Waimanalo Health Center patients aren’t showing up anymore, either. Mary Oneha, CEO, says the center will try to stay open as long as it can. But it already has had to cut hours for dentistry workers.

Waimanalo Health Center is now rolling out telemedicine services for the first time.

There’s definitely a learning curve. One Waimanalo doctor spent nearly two hours helping a patient set up the telemedicine application, she said. And Oneha worries that patients who don’t own computers or smartphones could be missed. In those cases, doctors follow up by phone.

“The disparities between the haves and have nots are becoming very apparent during this pandemic,” Vasconcellos said. “Ideally yes, telehealth is a solution but is it a practical solution for every community? Absolutely not.”

There has been some federal relief.

Usually, online health appointments must meet certain federal privacy standards. The federal Office for Civil Rights at the Department of Health and Human Services recognized that not all clinics would be able to meet them during the national emergency, so its officials said they would not penalize noncompliance as a “good faith provision of telemedicine during the COVID-19 nationwide public health emergency.”

‘Our Bottom Line’

Even though federally qualified health centers may not treat COVID-19 patients, the pandemic is already hitting their bottom line.

Vasconcellos said she expects federal medicaid reimbursements will nearly disappear, and the health center’s total revenue could fall as much as 35% as a result.

Hawaii will receive at least $4 billion in federal coronavirus relief funding, $11 million of which will be dedicated to community health centers, Sen. Brian Schatz announced Monday.

That’s a good start, Vasconcellos said, but it’s hard to predict if that’s enough to help community health centers survive the pandemic.

Without financial relief, Vasconcellos, Oneha and Taaffe said they fear they will have to cut more services, close certain clinics or furlough staff.

If it comes to that, Oneha said Waimanalo Health Center would look at further staffing and service reductions before closing entirely.

“That would only come if we completely run out of supplies or if we don’t have staffing for whatever reason,” she said. “I hope we don’t get to that point but we are having to scrutinize the number of visits that we are generating and where we are with our bottom line.”

Civil Beat reporter Brittany Lyte contributed to this report. 

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