Let’s stop the exodus of Hawai‘i’s doctors

The shortage of doctors is a national problem, but Hawai‘i is losing its doctors far faster than other states.

This is due to the business practices of Hawai‘i’s largest insurer, HMSA, and the regulatory climate in Hawai‘i. What is proposed here is a comprehensive solution to Hawai‘i’s problems. Interestingly, it requires no tax dollars. There is no budget to hide behind here. It only requires political spine to change the present dysfunctional system.

So, who am I to make such allegations?

I am a urologist. My brother is a urologist. My father is a urologist. The practice of medicine runs in my veins. I have degrees from two Ivy League universities. I have served on the faculty of the University of Florida and the University of Hawai‘i. I was the Chief of the Division of Urology for the University of Florida at Jacksonville for three years. I am a fellow of the American College of Surgeons. I have even served on the selection committee for the American College of Surgeons.

For the last 20 years I have served the Kona Community with an impeccable track record. I have served as Chief of Staff at Kona Community Hospital. I am 56 years old and will be closing this practice soon because of the regulatory climate here. My father was recently knighted by the French government. He practiced urology until he was 90 years old. He spent an hour with each patient.

My father made a pretty good living seeing 10 patients per day. Then the HMO’s came along. To make a living my daily patient load became 20, then 25, then 30, then 35. Doctors here either burn out or go broke. The patients lost something in the process. There is no aspect of the healthcare crisis that I do not see. As an employer, I buy lots of expensive healthcare insurance for my employees. As a patient, my doctor just left town. As a provider, I know why.

Hawai‘i’s doctor shortage has been likened to having a dangerous intersection in your neighborhood. Until there have been enough preventable deaths for blame to start to be assigned, the traffic light is not installed. The doctor shortage in this state will lead to preventable deaths. Little problems untended become big problems, and in my business big problems are frequently fatal. It is clear where the blame lies.

HMSA has to stop short-changing the consumer by paying less for the services of non-participating doctors, and has to stop the abusive practice of sending non-participating doctors’ checks to the patient rather than the doctor.

A large number of these patients who get the doctor’s check keep the check and do not forward it to the doctor. Furthermore, many of those patients then stop seeing that doctor because they are ashamed of having kept the doctor’s check.

It is in the community’s best interest to have non-participating doctors in the community rather than no doctors whatsoever. All of the doctors who have left this community in recent memory have cited HMSA’s business practices as a principle reason for their departure. So far HMSA has steadfastly refused to admit that they are part of the problem. HMSA should pay what they see fit for a doctor’s services (currently 30-70 percent below national standards), but HMSA should absolutely not be allowed to short-change the consumer by paying even less for the services of non-participating doctors. The services of non-participating doctors are in fact more valuable to the consumer because they are actually available.

So why should HMSA get to pay less on your claim, pocket the difference, and reduce your access to care by driving your doctor out of town in the bargain?

In a free market economy it is competition, and only competition, that keeps prices down and quality up. SHPDA and the Certificate-of-Need process is an anti-competitive protectionist law that grew out of a very brief period of time in the 1970s when the federal government paid for services based on the cost of providing those services. The feds very quickly dropped this approach, as did many other states, but Hawai‘i has enshrined it. Please Google this topic if you need to learn more about it. Ostensibly, this law exists to protect the hospitals, but who is protecting the consumer? For the public to have more and cheaper access to CT scanners, MRI machines, surgicenters, and a choice of hospitals this law needs to be abolished.

In other states doctors are allowed by federal law to have up to a 4 percent ownership interest in the laboratory, the CT scanner, the MRI machine, the surgicenter, the hospital, etc. This is generally not allowed in Hawai‘i.

Physician involvement in these business enterprises generally leads to better management, lower costs and easier access by the consumer. Interestingly, states that dropped the CON laws did not experience an increase in healthcare costs. Up to 40 percent of Mainland doctors’ income may be derived from these tiny fractional ownerships. Hawai‘i’s doctors are departing for states that allow them to participate in these enterprises. In a free market capitalist economy this is not surprising.

I currently pay four times what my counterparts in Texas pay for malpractice insurance.

Time is up.

Hawai‘i’s doctors are leaving. The consumer is suffering. We’ve had enough of the Trial Lawyers’ Association. The people should rightfully blame their state legislators for dithering here as the preventable deaths mount. Shame on state legislators for their disgraceful performance this year.

Surprisingly, the Jones Act also contributes to the non-viability to the medical practices in the state of Hawai‘i. Medicare pays the same reimbursement to doctors in parts of California as Hawai‘i. The Hawai‘i doctors have higher overhead due to the Jones Act, which significantly cuts into their profit margin. This outstandingly bad piece of protectionist legislation prevents foreign flagged vessels from carrying cargo between American ports. In light of the trade deficit the U.S. Mainland runs with Asia, huge numbers of freighters are coming back empty. We could utilize this cargo space to significantly reduce our cost of goods in Hawai‘i. The Jones Act makes it more expensive for all of us to live here, and particularly makes Hawai‘i a less desirable place for doctors to set up practices.

Sixty five as the age of social welfare was first chosen by Bismarck in Germany in the 1800’s. The life expectancy at that time was in the 50’s. In other words, he was willing to take care of the top few percent of the population. This is now one third of the population and growing. Our unimaginative legislators have attempted to cut the benefit pie into ever tinier slices in order to accommodate the mass of people. This has inevitably led to insufficient benefits for all. There is no substitute for raising the age of Medicare. This one move will ensure that everybody’s benefits remain at a viable level without busting the budget.

So far the doctor shortage has weighed most heavily on the outer islands. But the cookie always crumbles at the edges first, and this problem will surely spread across O‘ahu if the above changes are not made. Remember that I do not have a dog in this fight. I will soon be closing this practice and retiring against my will. I would like my legacy to my patients to be a demonstrable path to a viable healthcare system. We need to:

• Change HMSA’s detestible business practices

• Eliminate SHPDA and the Certificate of Need process

• Enact tort reform

• Eliminate the Jones Act

• Increase the age of Medicare.

Once again, these changes merely require a stiff political spine and not money. They will restore free market principles to a grossly distorted medical reimbursement system. I would point out there is at least some reason for guarded optimism here. We do not have to come up with a perfect solution. We merely have to make Hawai‘i a more doctor-friendly place than the states that are luring doctors away.

Political activism can accomplish this. We need HMOs with a conscience and legislators with some imagination and political spine. Both have been in short supply thus far.

It is very clear that HMSA, our megalithic insurance company, and legislators should be blamed for the impending preventable deaths from the doctor shortage in this state.

• Jon K. Lattimer, MD, FACS, is a urologist and lives in Kona on the Big Island.

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