Collaboration to Improve Severe & Growing

Doctor Shortages on Hawaii Island

October 21, 2010Sharon H. Vitousek MD

North Hawaii Outcomes Projectwww.nhop.org

Doctor Shortages on Hawaii Island

• The Problem

• Barriers to improvement

• Solutions– Hawaii Island Healthcare Alliance

WEST HAWAII TODAY March 14, 2005

Dr. Doug Hiller, an orthopedist, is one of the specialists frustrated by the system."You agree to leave your family for an unlimited amount of time, at any time during the day or night," Hiller said. "You agree to leave an office full of patients at any time. You agree to be exhausted the next day. You agree not to be paid for any of this."

WEST HAWAII TODAY March 23, 2005

“The price of practice has led to shortages of primary care physicians and a lack of specialists.‘A whole generation of young doctors didn't come here -- my colleagues and

I would have been mentoring them through the years, but we haven't,’ said

Dr. Steven Denzer, an internal medicine physician.

“We need your help to pressure the legislature to reform the regulatory climate….Paradise isn’t paradise, when you can’t find a doctor.”

-Jon Lattimer MD

WEST HAWAII TODAY March 23, 2005

"There should be a council of health care providers -- doctors, hospitals, clinics, everyone," Denzer said. "There are common causes. It's time to communicate and work together."

New Solution:

Island-wide Stakeholder Collaboration

to Improve Healthcare Access

“Hawaii Island Healthcare Alliance”

Barriers to Improvement• Fragmentation & lack of infrastructure

– Lack of Consensus on Priorities to Improve• Healthcare is Complex• Many players with different perspectives

– Patients– Providers, Hospitals, MD, “Mid-level providers", RN etc– Government/Regulatory– Payers/ Insurance– Vendors- Equipment/Pharmaceutical suppliers– Purchasers/Business/Individuals

• Hospitals (which often lead) are facing their own financial troubles

• Mostly solo and small group practices• Cost of the problem NOT clear

Who has taken lead ?• DOH?• SHPDA? SAC• Legislature/ Legislators?• County: Mayors office, R&D, Office of Aging?

• Hospitals/ HAH?• Doctors/ PA’s/HMA?• FQHC’s, Primary Care Association?• HRHA, HIRHA?• JABSOM?• Chambers/ Business? Insurance?

Hawaii Island Healthcare Alliance

Alliance

• Can reduce fragmentation

• Can provide vehicle for:– Collaboration & Connecting with resources– To clarify common vision, measures of

success:– Policy change– Reduce barriers to improvement

Can accelerate Improvement

Alliance Members• Providers: Hospitals, FQHC, Docs, PAs JABSOM,

CHI• Business: Chambers• Community• Government: DOH, SORH, Mayor’s Office• Workforce investment• Unions• Insurance• Advocacy

Guiding Principles

• Island wide approach

• Collaborative

• Inclusive

• Importance of Primary Care & Prevention

• Short term & Long term strategies

Focus

• Improve access to primary care and specialist care

• Support financially stable hospitals

Alliance Priorities

• UH Family Practice Residency! • Administrative flexibility for HHSC hospitals • Identify & Address policy barriers: effective & safe

use of broader primary care team: (PA’s, RNP’s, midwives) use of phone/ telemedicine, tort reform – Dialogue to promote consensus to Legislature

• Focus on Primary Care - Medical Home– Broader team of providers, PA’s, RNP

• Reduce gap between cost of providing care & reimbursement

• Collaboration on Recruitment & Retention

Alliance Accomplishments

Recommendations to 2009 LegislatureConsensus on need for UH Hilo Family Practice

Residency programConsensus on need for collaborative recruitment

& retentionIdentified policy barriers to effective PA practice -

worked with Medicaid on changeWork force training on revenue cyclePlanning to align 2010 policy efforts

Organizational Infrastructure

Vehicle- Fiscal Agent selected- FOFDecision making- CharterExec com, Officers to sign Need Funding for Infrastructure

• Admin/ partnership development• Communications• Information gathering/community meetings• Grant writing

Collaboration on Recruitment & Retention

Providers

Regional & Island wide planning for:ServicesSpecialists & call

Develop more opportunities to join a group practice or IPA

Increase opportunities for qualifying for loan repayment through NHSC

Recruitment & RetentionJABSOM/ Providers/ Business

Develop updated accessible list of current docs with contact info

Develop updated accessible list of current “job opportunities” and contact info for prospective recruits.

Recruitment & RetentionGovernment

Implement “Island status” to add COLA to CMS reimbursement

Improve HPSA /MUA designationsTechnical assistance with getting NHSC

qualification to help fund loan repaymentHealth Enterprise Zones

Recruitment & RetentionInsurers

Pilot test different reimbursement for Primary Care Medical Home

Work force training on revenue cycle Reduce barriers to appropriate charge for

phone communication with own patientsImprove information on cost by sharing

data on Avoidable Hosp/ER costs

Recruitment & RetentionCommunity

Improve community links with existing students and residents FROM Big Island

Improve community links with families of prospective and new & existing docs,

• Link with business startup loans

• Link with loan repayment opportunities,

What is our preferred futurefor next two years? --DRAFT

• Hilo Residency students start in 2013

• 3 High quality, financially stable Acute Hospitals• 4 High quality Critical Access Hospitals• 3 High quality FQHC• At least 10% increase in SNF beds• Adequate & Satisfied healthcare workforce – Retain, recruit at least 30 new physicians – X

(20) primary care, Y (10) specialists, Z PA’s

What is our preferred futurefor next two years? --DRAFT

• 90 % of population has a primary care medical home

• 80 % Have “visited doctor in last 2 yrs”• 5 % decrease in “Potentially Avoidable

Hospitalizations”

What is our preferred futurefor next 5-10 years? --DRAFT

• Ratios of doctors/population same as state average

• Hawaii County has same proportion of doctors as population ie 14 %

• Hawaii County death rates are at or below state average

• Hawaii County life expectancy is at least as high as the state average

Why do we think

a stakeholder collaboration

will really work?

Its worked elsewhere!

Lessons Learned Addressing Complex Problems

• Credible, compelling data engages stakeholders• Complex issues require multiple stakeholders

– State, County & National

Funding for infrastructure is essential• Prioritization & Short key messages• Specific recommendations

– Including Policy Change

• County leadership makes a big difference• Complex issues take time

– to address barriers and to show results

Growing Sense

of Shared Responsibility

It Is Our Monkey

PROBLEM

Quantitative

How Big is the Problem?Sources of info:

1. Census data on # of MD offices

2. Ratios: doctors / population

3. % of licensed state doctors IN HC compared to % of population

4. Population Surveys on access

5. Big Island Workforce Study

136137

146 146

150151

136

125

130

135

140

145

150

155

2001 2002 2003 2004 2005 2006 2007

Number of Hawaii CountyPhysicians Offices (2001- 2007)

Chart: North Hawaii Outcomes Project - October 2009

7 % -10%

1 %

3 %

1 %

Source: U.S. Census, Economic Census 2007

Code: 621111 Title: Offices of physicians (except mental health specialists) Sector: 62 Definition: This industry comprises establishments of health practitioners having the degree of M.D. (Doctor of medicine) or D.O. (Doctor of osteopathy) primarily engaged in the independent practice of general or specialized medicine (except psychiatry or psychoanalysis) or surgery. These practitioners operate private or group practices in their own offices (e.g., centers, clinics) or in the facilities of others, such as hospitals or HMO medical centers (U.S. Census-Economic Census).

Hawaii County Lowest Ratio of MD/Pop

*Licensed physicians may or may not be actively practicingThis number OVER estimates physician supply

Hawaii County, 14%

Honolulu County,70%

Kauai County, 5% Maui County, 11%

Percent Population by Counties

Source: U.S. Census March 19, 2009 Population EstimateChart: North Hawaii Outcomes Project - October 2009

Hawaii County5%

City & County Of Honolulu

41%

Maui County4%

Kauai County2%

Mainland47%

Foreign1%

Percent of Licensed Physicians - 2009*

Hawaii County

City & County Of Honolulu

Maui County

Kauai County

Mainland

Foreign

*Current licenses(7,608) as of April 1, 2009

Note: The Mainland and Foreign categories are licensed physicians who have a license to practice in Hawaii but use a mainland address as their primary address.

Chart: North Hawaii Outcomes Project, October 2009

Source: Numerator f rom Department of Commerce and Consumer Af fairs – April 1, 200*Denominator f rom U.S. Census March 19, 2009 population estimate

.may or may not be active** Licensed physicians

~20 % Do Not Have Doctor in Hawaii County

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2001 2002 2003 2004 2005 2006 2007 2008

Hawaii County City & County of Honolulu Kauai County Maui County

Have One Person They Think of As Their Do NotPercent of People Who Personal Doctor - 2001 - 2008

Chart: North Hawaii Outcome Project - October 2009 Source: Behavioral Risk Factor Surveillance Survey 2001 - 2008

BRFSS phone survey may underestimate problem

2005 2006 2007 2008

Kauai County 77.1% 76.4% 75.3% 72.9%

City & County of Honolulu 83.9% 82.5% 81.9% 79.7%

Maui County 81.5% 78.2% 78.8% 75.7%

Hawaii County 77.3% 76.9% 77.9% 74.0%

77.1% 76.4%

75.3%

72.9%

83.9%

82.5%81.9%

79.7%

81.5%

78.2%78.8%

75.7%77.3% 76.9%

77.9%

74.0%

66.0%

76.0%

86.0%

Perc

ent v

isite

d a

doct

or

Visited a Doctor Within the Last Two Years2005-2008

Chart: North Hawaii Outcome Project - October 2009 Source: Behavioral Risk Factor Surveillance Survey 2005 - 2008

Kelley Withy, MD, PhD David Sakamoto, MD, MBA withy@hawaii.edu dts@hawaii.edu

UH John A. Burns School of MedicineArea Health Education Center

808-692-1060

Additional Issues Increasing size of the Problem?

• Aging Health workforce Average Age MD = 56• Aging Population• Relatively Higher Burden of Disease:

– Social determinants • Increasing Poverty- Increasing Income inequality• Low educational attainment

• Rural & Geographic isolation

Consequences of Shortage

Higher admission rates for “potentially avoidable Hospitalizations” (ASC)1. HTN

2. CHF

3. Pneumonia

Consequences of the Shortage

Consequences of the Shortage

Higher Death Rates1. All causes

2. Overall cancer

3. Infant death rates

4. Stroke death rates

Consequences

0

100

200

300

400

500

600

700

800

900

1000

1999 2000 2001 2002 2003 2004 2005 2006 2007

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Hawaii County

State

Adjusted Death Rate-Age-All Causes Hawaii County Compared to the State

Chart: North Hawaii Outcomes Project - April 2009 Source: Office of Health Status Monitoring, 1999-2007

Consequences

0

50

100

150

200

250

300

350

400

450

500

1999 2000 2001 2002 2003 2004 2005 2006 2007

Dea

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Hawaii county

State

Chart: North Hawaii Outcomes Project - April 2009 Source: Office of Health Status Monitoring, 1999-2007

Death Rate-Overall CancerHawaii County Compared to the State

6.7 6.6

4.7

5.3

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Hawaii County City & County of Honolulu Kauai County Maui County

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Infant Mortality (County of Residence)Average Rate 2000-2007

Source: State of Hawaii Health Department, Vital StatisticsChart: North Hawaii Outcomes Project - October 2009

Evidence Linking Death Rates with Access to Primary Care

Harvard/ Hopkins study of all US Counties

Protective FactorsRatio of Primary

Care Physicians Education Level“Social Cohesion”

Source: Leiyu Shi, Ichiro Kawachi, Ph.D. Income Inequality, Primary Care, and Health Indicators J Fam Prac 1999 48: 275-284

Consequences of the Shortage

• More complications? - NEED DATA

• More ER visits? - NEED DATA

• Higher costs? - NEED DATA

Root Causes

Summary of Causes:

• $$- Can’t make it financially• Time & work life balance:

– Too much call, – High volume required to make ends meet,– Lack of docs to refer to, impacts life style

• Isolation:– Professional

• Solo practice or small groups, Too busy

• Long distances, lack of leadership

– Social family

Causes:

$$$--- Cant make it financially

• Large & growing financial gap between cost of providing care and reimbursementWorse with solo/ small practices– Worse with more Underinsured, Uninsured, &

Unemployed– Worse with high cost of living--housing, education– Worse with no COLA

Hawaii Lowest Medicare Spending per Beneficiary

Impact on Quality and Access

Source: “Medicare Spending, the Physician Workforce And Beneficiaries’ Quality of Care”

Health Affairs Katherine Baicker and Amitabh Chandra,

7 April 2004

Hawaii island Healthcare Alliance

Source: “Medicare Spending, the Physician Workforce And Beneficiaries’ Quality of Care” Baicker & Chandra, Health Affairs ,7 April 2004

Acknowledgements

• Data collected analyzed displayed by NHOP form primary & secondary soruces

• www.nhop.org supported by the

• Earl & Doris Bakken Foundation