For many years, we’ve struggled with the shortage of physicians in East Hawaii.
For certain specialties, we just don’t have the population base to support a specialist. Maybe telehealth can increase access to these specialists. For primary care, however, it’s essential that there is access for everyone who lives in East Hawaii. Otherwise, their health will be compromised, and in the end, they will need more expensive and intensive treatment.
The situation is getting critical as older primary care physicians in private practice retire or approach retirement.
Since they’ve been a part of the community for a long time, these physicians care for a disproportionately large number of us. My own primary care physician, who just happens to be my brother, is one of those physicians nearing retirement and has served so many of us for more than 30 years.
The East Hawaii Independent Physicians Association reports that 40 percent of the patients their physicians care for are attributed to physicians more than 65 years old. If we keep thinking the problem is not enough physicians, however, we are framing it in a way that is insoluble. There is an acute shortage of primary care physicians nationwide, and it is difficult to get physicians to live in Hilo for the long term.
The problem is access to primary care, and that problem we can solve. Last month I participated in Community First’s Strategic Planning Retreat chaired by Barry Taniguchi and Darryl Oliveira with community leaders and executives from HOPE Services, Hawaii Care Choices, the County Office of Aging, Bay Clinic, EHIPA and Hilo Medical Center. Our consensus was that primary care should be team-based. When care is team-based, everyone works at the top of their license.
This is a fundamental principle of a medical home. A physician should oversee the quality of care provided by the team of a medical home, but should not be doing what a nurse or physician assistant can do; they should be spending their time with patients with the most complex conditions.
By working as a team, they can care for many more patients than a physician working alone. New per-member, per-month payment models versus the old fee-for-service models also favor team-based care. Practices have to achieve some economies of scale. It could be physicians practicing as a group, or they could be employees of a large health care system. But whichever way it goes, I hope we don’t lose the personal touch that so many of us enjoy from private practice.
At the planning retreat, Dr. Lynda Dolan shared how team-based care doesn’t have to mean the loss of the personal touch from the physician. Her nurse treated a patient for a cold, but when Dolan ran into her patient at KTA and asked about her cold, the patient was surprised that Dolan knew about it and appreciated that the doctor was still taking care of her, even though the visit was with the nurse.
Done well, team-based care in a medical home can provide more access (with less waiting time for patients) without impairing the quality of care or the personal touch of private practice. It is critical, however, that we understand and accept this as a community, otherwise it will be difficult for physicians to change their practices.
Recruiting and retaining enough physicians to come to practice and live in Hilo to meet the need for primary care might not be possible, but each year more than 10 students graduate as advance practice registered nurses from the University of Hawaii at Hilo Nursing School. Many of them have local ties and all of them at least know the community. Hawaii law allows these graduates to be independent primary care providers. But setting up a private practice is daunting, even as a physician.
As a community, we need to develop a business and practice model which integrates APRNs, physician assistants and other midlevel providers into the delivery system. We need the East Hawaii IPA, Hilo Medical Center and Bay Clinic to work together and with us to ensure access to primary care.
As surely as everyone ages and retires at some point, the disaster of not having access to primary care will be upon us in the next five years or so. In addition, and almost as certain, will be the continued population growth in East Hawaii, where some of the most affordable land and home prices in Hawaii can be found.
We must act now to develop solutions to ensure that access to primary care for everyone is a reality in the years to come. Moving forward, we should remember Barry’s three principles: “Only together.” “Make the invisible, visible.” “Try, and don’t expect to get it right the first time.”
If we act as a community, we can solve the problem of access to primary care.
Randy Kurohara previously served as Hawaii County managing director and is a longtime local business owner.
This column was prepared by Community First. Led by KTA’s Barry Taniguchi and a volunteer board of local community leaders, Community First seeks to help the community respond to the health care cost crisis and support initiatives that change health care from just treating disease to caring for health.
For those of who have served the East Hawaii community for years independently, we prefer not to be referred to as “mid-level providers”, nor “physician extenders. I do more and get paid much less that my MD peers.
Most seasoned NPs will not accept the low insurance reimbursement rates and disrespect we encounter here. They gravitate to states like Washington and Oregon, where independent practice and equal pay for equal work is the norm. I remain motivated by the need of our under-served mentally ill residents. Nineteen years and counting.
Things must have really changed in WA state. I lived there twenty years, in a small town and most the time we had a NP deal with the the few medical problems we had, but he had to work under the supervision of an MD.
Here in Hawaii a few years back I tripped in the dark and tore my arm open pretty good. The NP refused to sew it up, called in a doctor to look at it, and the doctor put the 15 stitches in. So I guess NP’s have their limits.
Some NPs have their limits. If properly trained, the NP could do the suture; provided the employer was open to allowing the NP to work to the top of their license and training. A lot depends on the individual quality of education and length and quality of experience, as with all other professionals. We are fully independent in HI, WA and OR. now; a professional right we had to fight for due to the medical guilds’ fear of competition. The pay here is much less than the west coast though and some medical settings are still kicking about what is considered snanddr elsewhere.. Still not leaving. My patients need me.