With a lack of family practice doctors, obstetrician/gynecologists, orthopedists and other specialists in poor and rural areas of Hawai'i, state lawmakers are drafting financial incentives to help lure doctors from town to the country.

New doctors who agree to practice for five years in areas where there are shortages would be eligible to have their medical school tuition and student loans covered by the state. Established doctors who devote half of their practices to poor and rural areas, or one-tenth to help the uninsured, would be eligible for yearly stipends of up $10,000.

The proposal, called the Hawai'i Health Corps, would target a maximum of 20 doctors a year in the tuition and loan forgiveness program and 100 doctors in the stipend program. Lawmakers are also discussing the creation of health enterprise zones in poor and rural areas where healthcare providers would get a general-excise tax exemption for setting up new healthcare facilities, such as trauma or long-term-care centers.

"I'll try anything I can to move some of the healthcare dollars to fight this crisis," said state Rep. Josh Green, D-6th (N. Kona, Keauhou, Kailua, Kona), a Big Island doctor and chairman of the House Health Committee.

The Hawai'i Health Corps is part of the House Democrats' majority package of bills for the session that opens on Wednesday, as lawmakers figure out how to answer complaints from patients and healthcare advocates about access to quality care.

The Lingle administration and the Hawai'i Medical Association, however, are again urging lawmakers to consider medical-malpractice insurance reform, which has been cited as one of the reasons doctors are leaving or declining to come to the Islands. The HMA, which represents doctors, has received a $100,000 grant from the American Medical Association for a public relations campaign on malpractice reform.

MONEY'S LIMITED

Access to healthcare is one of the issues lawmakers will address this session, the second in the state's two-year budget cycle. The state Council on Revenues downgraded the state's revenue forecast last week because of the slowing economy, so there will likely be immediate budget restrictions and less money for state lawmakers to spend next fiscal year.

With a limited amount of dollars on the table, new initiatives such as the Hawai'i Health Corps will have to be justified in the context of other priorities such as public education, affordable housing and environmental protection. Economists have suggested to the Legislature that bond-financed capital improvement projects may be a good investment this session, both because there are obvious needs at public schools, the University of Hawai'i and state airports and harbors, and also as a hedge against any downturn in private-sector construction.

Doctor shortages in poor and rural areas are a problem nationally, not just in Hawai'i, although the Islands' geography poses unique challenges. Doctors have cited lower reimbursement payments from the government and private health insurers, higher medical-malpractice insurance premiums, and quality of life issues, including lower pay, as factors that contribute to the shortage.

But for many patients who have trouble finding a specialist, or are losing a doctor they trust, the complexity of the issue is irrelevant. They just want doctors they can depend on for care.

Tracy Janowicz, who lives in Wahiawa and works in youth services, said she has a rare blood defect that causes her blood to randomly clot. She said she lost her doctor in Wahiawa a decade ago when he left for Doctors Without Borders, an international humanitarian effort to help people during war, epidemics and natural disasters. She found a doctor in Kailua that she grew to trust, but the doctor retired last year, mainly because of fear of malpractice lawsuits.

"We go to doctors because we believe in them," Janowicz tearfully told lawmakers Thursday at an informational briefing at the state Capitol sponsored by the HMA. "To me, it's very personal."

Last session, Green, with the backing of the Healthcare Association of Hawai'i, which represents hospitals and other healthcare providers, proposed diverting $100 million in state tax revenue each year into a new special fund to pay for critical healthcare services. Despite some early sparks, the idea quietly faded.

This session, with the Hawai'i Health Corps in the majority package, Green is more hopeful. Practical details, such as the total cost, exactly how doctors' tuition and student loans would be repaid, and how the enterprise zones would be developed, are still being discussed among House leaders.

"We're trying to shift the economic curve so that we can actually build out critical health care infrastructure," Green said.

Green is also interested in prodding private health insurers, such as the Hawai'i Medical Service Association, the state's largest, to raise reimbursement rates to doctors. Lillian Koller, director of the state Department of Human Services, which oversees the state's health insurance program for the poor, has also tweaked HMSA over payment rates.

GOVERNMENT FAULTED

HMSA executives, in a briefing Thursday with The Advertiser's editorial board and reporters, said government reimbursement rates under Medicare and Medicaid have not kept pace with healthcare costs. HMSA believes it is unfair for lawmakers to shift doctor and hospital costs to the private sector where, essentially, HMSA's members would subsidize the government programs.

"What is happening is an unfunded mandate that's thrust upon commercial payers by government programs not stepping up to the plate and paying their fair share," said Steve Van Ribbink, HMSA's executive vice president and chief financial officer.

State Sen. David Ige, D-16th (Pearl City, 'Aiea), the chairman of the Senate Health Committee, said he would think about Green's Hawai'i Health Corps proposal. But he wondered if it would be better for the state to invest more in the Hawai'i Health Systems Corp., the state's quasi-public state hospital system and the largest healthcare provider on the Neighbor Islands, and in the federally qualified health centers that work closely with the poor in regions such as the Wai'anae Coast.

"That is the first level of healthcare services for those communities," Ige said.

Ige has asked the Lingle administration and the HMA to identify the things that drive up the cost of medical malpractice insurance and to show how reform would lead to lower premiums for doctors and greater access to care for patients.

State Rep. Tommy Waters, D-51st (Lanikai, Waimanalo), chairman of the House Judiciary Committee, has informed the HMA that he will not hear a malpractice reform bill this session after the committee rejected it last year.

Waters said he would consider Green's Hawai'i Health Corps as well as a new tax credit to help offset the costs of malpractice premiums for doctors who practice in rural areas.

"Ultimately, given the budget this year, it's going to come down to whether the House Finance Committee will go for it," Waters said.

The Lingle administration and the HMA favor a $250,000 cap on certain aspects of medical malpractice lawsuits that would limit damage awards for emotional distress and the loss of companionship. The state has a $375,000 cap on pain and suffering damages.

Some who want malpractice reform believe they were outmaneuvered at the Capitol last session by trial lawyers, who brought in people who have experienced disastrous medical errors to testify about the importance of preserving the ability to recover appropriate damages from negligent doctors. The HMA, through informational briefings and the public-relations campaign, is seeking to reframe the issue this session so it is about patient access to care instead of a fight between doctors and lawyers.

Paula Arcena, the HMA's executive director, said she was open to Green's Hawai'i Health Corps.

"It looks like something positive that we would support, but it's not a replacement for meaningful liability reform," she said.

Janowicz's former doctor, Helen Ing, an internist in Kailua, said she retired three months ago. She said her husband, a cardiologist, was sued for malpractice and while the case has been resolved, the experience was too stressful for her and her family and she chose to retire rather than risk future lawsuits.

"I miss my patients a lot," Ing said. "A lot."

Reach Derrick DePledge at ddepledge@honoluluadvertiser.com.