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The Honolulu Advertiser
Posted on: Monday, February 13, 2006

Isles headed for healthcare crisis?

By Rob Perez
Advertiser Staff Writer

Nurse Gina LeTourneur and hospital aide Ada Tsuji stock items for a tamponade cart, used to stop bleeding in the heart after open-heart surgery, at Kaiser Moanalua. Hospitals are suffering from a shortage of nursing and emergency care personnel.

REBECCA BREYER | The Honolulu Advertiser

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A few months ago, an 80-year-old man was rushed to a Big Island hospital with a broken hip.

Instead of being admitted, seen by an orthopedic surgeon, then put on the surgery schedule for the next day, the man had to wait.

And wait.

He spent 24 hours in the emergency room, eventually was transferred to two other Big Island hospitals, then had to be flown to an O'ahu facility where an orthopedic surgeon was available to treat him.

Two days after his initial injury, the man finally had his operation.

Dr. Josh Green, a Big Island emergency-room physician and a state House member, recalled the case to help illustrate what hospital officials in Hawai'i consider a mounting crisis.

For years, Hawai'i hospitals, like medical institutions across the country, have struggled to address major financial pressures as operating costs have surged. That has cut into the availability of speciality care, especially in rural areas. Some hospitals on the Mainland and in Honolulu have eliminated or scaled back programs to help cope with the crisis.

In the midst of the financial turmoil, Hawai'i's medical system has not scored well in recent quality surveys, suggesting that the pressures are taking a toll on the care provided to patients. Hospital officials dispute that, saying only availability and variety, not quality, have been affected thus far.

But unless more is done to address what the industry describes as a "perfect storm" of circumstances coming to a head, additional services could be at risk and more people increasingly will experience delays in getting certain types of care, such as having to travel farther from rural areas to get treatment, hospital executives and others say.

"Our citizens have been so used to having a real good healthcare system and having it readily available," said Richard Meiers, president of the Healthcare Association of Hawai'i, the lobbying group for hospitals, nursing homes and other providers. "Our big concern is that it's not going to continue that way once this perfect storm comes together."

The primary factors contributing to the crisis, according to Meiers' organization, are:

  • Reduced reimbursement rates from the federal and state governments to cover the cost of caring for Medicare and Medicaid patients. The reimbursements cover only 37 cents for every dollar of care provided, and officials fear the Medicare rates could drop even more.

  • The high cost of caring for elderly patients, including those in long-term-care facilities.

  • Increased care for patients who are unable to pay all or portions of their bills. Since 2000, the industry has lost more than $571 million to provide such care. Including all expenses and revenue for hospitals, the industry has suffered a net loss of $188 million from 2001 through 2004, according to Ernst & Young, the accounting firm that has studied financial trends for Meiers' group.

  • The millions of dollars that must be spent to comply with increased federal regulations.

    'ready to implode'?

    It's not just hospitals that are being affected, according to Meiers, legislators and others. Physicians, nursing homes and other providers are affected, and the problems are compounded by shortages of skilled personnel in areas such as nursing and emergency-room specialists.

    "We have a system that is getting ready to implode on itself," said Sen. Rosalyn Baker, D-5th (West Maui, South Maui), who heads the Senate Health Committee.

    And when one part of the system is affected, ripples can be felt elsewhere.

    Because Hawai'i has a shortage of long-term care facilities, for instance, elderly patients who should be in nursing homes take up acute-care bed space at hospitals. That puts a strain on other parts of the system.

    On one recent weekday, four O'ahu hospitals were filled to capacity some space was occupied by long-term care patients and had to inform the city's ambulance operation that they couldn't take more patients that day.

    Another example: A Kahuku physician's obstetrics practice has been affected because Kahuku Hospital stopped providing child-delivery services late last year except in emergencies, according to Don Olden, the hospital's chief executive.

    The hospital stopped the service, which delivered 100 to 120 babies a year, because the anesthesiologist in the program decided to leave, citing the poor economics of serving the rural hospital, Olden said.

    For pregnant women in the area, that means going an extra 25 to 30 miles to the next nearest hospital to deliver their babies, even though Kahuku is only minutes from their homes.

    Kahuku, like some other rural hospitals, runs a deficit every year, and the prospect of closing its doors always remains a concern.

    "The only way this hospital can survive is to continue getting support from the state," Olden said.

    The hospital received $1 million from the state in the last fiscal year.


    Honolulu's larger urban hospitals haven't escaped the effects of the storm.

    The Queen's Medical Center, the largest in the state, has become more efficient but also cut a few programs, such as a rehabilitation service for heart patients and a sick-child care program, according Arthur Ushijima, chief executive for Queen's. The hospital made sure the services were offered elsewhere in the community before cutting them.

    Queen's also is pursing outside funding from philanthropic groups and other sources for the first time, Ushijima said.

    At Kaiser Permanente, officials have scoured all facets of their business to look for ways to cut expenses without affecting patient care, they said. In January, for example, Kaiser decided to stop serving lunches at medical staff meetings. The expected savings will be $300,000 a year.

    Industry officials insist that measures they have taken to respond to the financial pressures have not compromised quality of care.

    "You can't put out bad healthcare and expect to succeed," said Kevin Roberts, president of Castle Medical Center.

    But Aggie Pigao Cadiz, executive director of the Hawai'i Nurses Association, said anecdotal information, such as delays in responding to patient call buttons, suggests that the financial pressures are affecting quality of care.

    "It would be very difficult not to have that affect quality," Cadiz said.

    Recent surveys indicate that quality in Hawai'i needs a shot in the arm.

    In a quarterly quality survey by the Joint Commission on Accreditation of Healthcare Organizations, which evaluates the nation's hospitals, Hawai'i institutions scored below the national average in 16 of 20 heart-care and pneumonia treatments rated.

    The American College of Emergency Physicians likewise gave Hawai'i a C-minus for its emergency medical care system in a national survey released last month. In the area of quality and patient safety, Hawai'i received a D+, according to the survey.

    Despite the mediocre results in the recent quality surveys, Kaimuki resident Elizabeth Apana, 58, said she has been pleased with the services she received at her hospital. Over the past year, she has gone to Kaiser six or seven times to get treatment for heart and back problems.

    "I'd say the quality was excellent," Apana said.


    Industry officials are lobbying the state Legislature this session to provide some relief from the multiple challenges confronting them.

    Among the measures is a bill to appropriate $40 million to help offset the money hospitals and nursing homes are losing on uncompensated care, according to Meiers, the industry lobbyist.

    Everyone agrees that the financial pressures are so pervasive, multidimensional and costly to address that solutions will have to come in increments. But if action isn't taken now, the ill effects will continue to spread, they say.

    "I don't think we're going to be shutting down emergency rooms, but the concern is quality of care and the level we can provide," said Rep. Dennis Arakaki, D-30th (Moanalua, Kalihi Valley), who is chairman of the House Health Committee. "It's especially critical because we're in the middle of the Pacific. It's not like we can send patients to the next state."

    Reach Rob Perez at rperez@honoluluadvertiser.com.