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The Honolulu Advertiser
Posted on: Sunday, December 21, 2008

LOW PAY, HIGH COST OF LIVING DRIVING EXODUS FROM NEIGHBOR ISLANDS
Some Hawaii islands short on physicians

 •  Funding dropped for rural residency program

By Christie Wilson
Advertiser Maui Bureau

Hawaii news photo - The Honolulu Advertiser

Hilo Medical Center on the Big Island doesn't have enough physicians especially in specialty fields to serve the community.

Hilo Medical Center

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Even his status as Big Island mayor couldn't get Harry Kim a visit with a neurologist after suffering disabling back and leg pain a few days before leaving office.

Kim, 69, began experiencing pain Nov. 26 but waited until after Thanksgiving to seek treatment at Hilo Medical Center, where he was given painkillers and underwent an MRI scan. The county's lone neurologist was off island at the time, and Kim couldn't get a neurology appointment until Dec. 23 in Honolulu.

In the meantime he's undergoing pain-management therapy.

"It's really difficult to get an appointment," Kim said.

Kim's predicament underscores the ongoing physician shortage on the Neighbor Islands, particularly in specialty fields.

Before Hilo Medical Center hired Dr. Elvin Hamlin in June, there were no neurologists on the Big Island, according to Hilo Medical Center spokeswoman Elena Cabatu.

"We've become very good at stabilizing patients to ship them out to other hospitals," she said.

Only one orthopedic physician is left on the Big Island after three others moved away in recent months, and only three cardiologists are serving the East Hawai'i region, including one recently hired by the hospital.

"Neurology isn't the only area we are short, it's pretty much every area and this includes the basics from family practice physicians to obstetricians and pediatricians, too. We do not have enough physicians to care for our community," Cabatu said.

A shortage of neurologists can impact treatment of stroke patients brought to hospital emergency rooms, and reduce the number of people able to return to work after injuries or other ailments, said Dr. Jordan Popper, president of the Hawaii Neurological Society.

"I have lots and lots of patients who are working half-time and full-time jobs with neurological illness and pain who are functioning because they are being treated by a neurologist," he said.

Neurologists deal with disorders of the central nervous system, including brain and spinal cord injury, stroke, pinched nerves, sleeping disorders, epilepsy, Alzheimer's disease and other neurodegenerative conditions.

Popper, 79, estimates the entire state has only 28 neurologists when there should be at least 40. Eleven moved away, retired or died in the past two years, he said, and only two have arrived to replace them.

Popper said neurology generally is "unpopular" in the insurance, government and business sectors because the specialty deals with complex disorders that require costly tests and treatment and is often involved in workers' compensation cases.

He said neurologists are "under attack" from a variety of sources, including federal and state law enforcement restrictions on prescribing pain medication that discourage doctors from taking pain management cases, and health insurance limits on lab tests and other diagnostic measures and use of nongeneric drugs.

"They are angry at us for ordering too many diagnostic procedures, but that's what we're there for. Family physicians send them to us because that's what's needed," Popper said. "Medications are not cheap and MRI studies are expensive. Unfortunately, anything that's central nervous system-based is going to be costly."

Because of the hassles, he said, "nobody wants to go into neurology anymore," except for research positions.

But apparently plenty of people want to see a neurologist. Popper's Honolulu practice has a one- to two-month waiting list for appointments, and the wait is double that for some pediatric neurologists, he said.

LOW REIMBURSEMENTS

Doctors say it's no mystery why so many physicians, in general, are leaving Hawai'i or declining to come here in the first place. They commonly cite low physician fee-for-service rates paid by Medicare, Hawaii Medical Service Association and other third-party insurers, and the state's high cost of doing business and living.

"This state is in serious, serious trouble. The reimbursement issue is killing us. Doctors will not come out here when they can make two to three times as much for the same amount of work anywhere else and the cost of living is so high," Popper said.

There are additional challenges on the Neighbor Islands, including a higher percentage of uninsured and low-income patients, subpar medical facilities and equipment in some cases, unreasonable on-call hours because there are fewer colleagues to share the load, and smaller populations that can't support specialty practices.

Other turnoffs are quality-of-life issues such as poor-quality public schools, exorbitant housing costs and difficulty adjusting to a rural lifestyle.

But the biggest complaints are about physician fee-for-service rates.

The reimbursement rates for services provided under Medicare, the federal health insurance program for the elderly and disabled, are determined by a number of factors, and many private insurers and insurance programs such as workers' compensation use Medicare rates as a benchmark.

Under the Medicare fee-for-service program, a relative value is assigned to each of more than 7,000 types of physician services, taking into account the amount of work, overhead expenses, and the malpractice premiums typically involved in furnishing the service.

For each of these components, the relative values are adjusted for the cost differences in various geographic localities.

According to the Centers for Medicare & Medicaid Services, the adjusted values for a particular service are multiplied by a fixed-dollar conversion factor to determine the payment amount for each service.

The agency updates the conversion factor annually using a statutory formula that sets a target rate of spending for a year, and then adjusts the update in subsequent years to keep actual spending over time in line with the target, CMS said. Since 2002, the formula has yielded a negative update to the conversion factor, and every year since 2003, Congress has enacted legislation to prevent the negative update from taking effect for the year.

This year, Congress increased payment rates by 1.1 percent for calendar year 2009, staving off a 5.4 percent rate reduction that would have otherwise resulted.

Physicians can qualify for new incentive payments totaling 4 percent of their Medicare-allowed charges by participating in the Physician Quality Reporting Initiative and a separate program that rewards doctors who adopt electronic prescribing, which can eliminate medication errors that result from handwritten prescriptions.

So, a physician who reports under both the e-prescribing and quality reporting initiatives could receive a 5.1 percent pay boost for 2009.

PHYSICIANS' COSTS

The pay increase and incentives are not seen as adequate remedies for Hawai'i doctors, who argue the state's geographic adjustments in no way represent the actual cost of doing business here. They also claim that the cost index is low because the Hawai'i locality includes Guam, where expenses are lower.

However, CMS officials told The Advertiser that only Hawai'i data are used in the calculations, since no baseline figures are available for Guam.

CMS said that out of 89 geographic localities, Hawai'i's geographic adjustment factor ranks 21st highest. Put another way, Hawai'i's GAF is higher than 75 percent of the 89 localities.

The officials noted the Hawai'i GAF is 4.8 percent above the average for all localities, and 7.1 percent higher than the median GAF.

In response to nationwide physician concerns that the configuration of certain localities no longer reflects the costs incurred by the physicians in certain areas of those regions, CMS officials said they are studying options for reconfiguring the localities.

The fee-for-service rate schedule for HMSA, the state's largest health insurer, is 115 percent to 120 percent higher than Medicare's, according to senior vice president Cliff Cisco.

The nonprofit organization has approximately 700,000 members, and 2,500 doctors, or about 90 percent of the state's physicians, are HMSA providers.

Cisco noted that HMSA will increase its fee schedule by 6 percent effective Jan. 1, and offers bonuses based on patient surveys, clinical measures and use of cheaper generic drugs that are similar to incentives provided by Medicare.

In 2008, HMSA awarded physicians $9.9 million under its Practitioner Quality and Service Recognition Program

"That is where the whole country is going, toward more quality measures, and we're following that track," he said.

Often overlooked in the dispute over physician fee-for-service rates are the impact of increases on employers and their workers, who are paying an increasing share of their healthcare coverage, he said.

"When you look at it from a community point of view, we're paying the physicians and hospitals as much as we can get out of the employers, who finance the majority of care in Hawai'i," Cisco said. "It's a balance between how much you raise the employers' rates and how much you can pay the providers."

Reach Christie Wilson at cwilson@honoluluadvertiser.com.