This state is facing a major crisis in access to medical care, especially in the trauma setting. There is an acute shortage of orthopedic surgeons. A week does not pass when I don't get called by a Neighbor Island hospital to accept care of an injured child because there is no orthopedic surgeon available there. And many of the Neighbor Island trauma centers do not even have orthopedic surgery coverage.

Adult trauma care is being covered by just two orthopedic surgeons at The Queen's Medical Center. Pediatric bone and joint injury is covered by two of us at Kapi'olani Medical Center for Women & Children. I can foresee that this situation will not be sustainable. What happens if one of the Queen's physicians is ill? How many times can I leave my own children at dinner or bedtime to care for an injured child? I can recall that my first child would spontaneously chirp "bye-bye, Daddy" as a toddler when my pager would ring. I left each time with the realization that I spent more time caring for other children than my own.

I make every effort to balance my personal and professional life; but the ever-increasing demands of providing care with fewer surgeons available to share this responsibility make it harder to do so. Nevertheless, I believe the people of this state deserve ready access to specialty care and I know that I would want my own family members to get the best care possible on a timely basis.

It is nearly impossible to recruit physicians to Hawai'i to help ease the situation due to the decreasing reimbursements and increasing malpractice costs. We continue to lose some of our finest surgeons to the Mainland. Three more orthopedic surgeons have decided to leave Hawai'i this year because of these issues.

The problem can be found in our "single payer" system that has vested so much unregulated power in one insurance "health" plan. The problem also is aggravated by lack of real tort reform.

The largest health plan has the power to drive competition from our marketplace (ever wonder what happened to Kapi'olani Health, Queen's Health Care, etc.?), set fees to employers without oversight, set reimbursements to physicians well below Mainland levels without regulation, and amass a ridiculous surplus of almost three-quarters of a billion dollars as a nonprofit for no apparent reason.

As physicians, we have no power to collectively bargain, so the health plans can set reimbursements far below fair and customary payments on the Mainland. HMSA has announced that it is increasing physician reimbursements by 3 percent this year. However, you have to realize that its reimbursements fall behind the Mainland by almost 25 percent already.

I don't think this announcement will bring back any doctors who have left the state. Furthermore, the fee "increase" is nested in financial double talk. Procedures that are done more commonly are actually seeing a fee reduction. So the local surgeon will likely see a reduction in his/her overall payments from HMSA in the months ahead. No government oversight of insurance plans is required in Hawai'i as the Legislature did not renew its legal mandate to regulate this industry in our state. The net result is that the health plans are driving subspecialty care from our islands and reducing access to quality subspecialty care.

I will give one more personal example of the frustration all surgeons are experiencing dealing with the largest health plan in the state. I specialize in bone and joint problems in infants, children and adolescents, with an emphasis on problems of the hip. I have been asked to perform hip preservation surgery on young adults with the intent to prevent osteoarthritis and a future artificial hip replacement. I undertook extra training in Boston in 2005 at my own expense to learn the latest techniques in hip preservation surgery and to bring these techniques back to Hawai'i. Upon my return, I met regularly with HMSA to determine an allowable charge for these procedures. The health plan set their reimbursement at half the fee paid to surgeons in Boston.

To make matters worse, HMSA recently retracted payment for one of these surgeries with no opportunity for me to appeal except to call the medical director. In essence, they paid approximately one-tenth the Boston fair and customary charges. The matter is still unresolved, and I cannot afford to commit more time to developing new programs and to bring new techniques to Hawai'i if HMSA does not value that innovation. Anyone in Hawai'i desiring these specific techniques in hip preservation surgery now has to travel to the Mainland for treatment.

Finally, the issue of increasing malpractice costs is a burden that is forcing surgeons to leave Hawai'i. I quote Dr. John Bellatti: "Tort Reform does not impede anyone's ability to sue a doctor for malpractice; it just means your attorney may give you better advice on what is realistic to expect. ... In an ethical Legislature, Tort Reform would already have come to a vote at least once. ... Don't let them dodge the issue again. Rain down e-mail, faxes, letters and phone calls. We need Medical Tort Reform now."

Robert C. Durkin, M.D., specializes in children's orthopedics and is president of the Hawai'i Orthopedic Association. He wrote this commentary for The Advertiser.