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‘Doctor shortage’ forums highlight crisis but also potential policy remedies

Hawaii is in big trouble when it comes to its healthcare capacity, according to three panelists who participated last week in forums on Maui, Oahu and Hawaii island about Hawaii’s statewide doctor shortage.

The  events were sponsored by the Grassroot Institute of Hawaii and featured Drs. Scott Grosskreutz and Elizabeth Ignacio and practicing physician associate James Winkler.

The forums were enthusiastically received by the attendees — and even more so on social media. About 100 people attended the three in-person events, but three short videos on the social media site TikTok have now reached almost 630,000, with many of the thousands of comments coming from doctors explaining why they moved away or will not consider practicing here to begin with.

At the Oahu event, Winkler, founder and CEO of the Kauai Community Health Alliance, detailed the crisis on Kauai:

“We have no endocrinologist, we have no outpatient neurologist, we have no oncologist. We don’t have a psychiatrist on our island. We have no geriatrics. We have no palliative care medicine. Our ophthalmologist won’t see Quest patients. I just had a patient with senile macular degeneration and diabetes. I tried to get them into an ophthalmologist, and they told me, ‘Send this person to Costco.’”

Reporting on the Hawaii island event, journalist Grant Phillips noted in the Hawaii Tribune-Herald that, “Hawaii island is short roughly 300 physicians, and statewide, that number is estimated to be well over 1,000.”

He quoted Grosskruetz, Hawaii island radiologist and founder of the Hawaii Physician Shortage Crisis Task Force: “Our health care workers in general are understaffed, they’re overworked and they’re aging out. It’s going to really take the general public and the community to lobby for these things to get them passed this session.”

Specifically, Grosskreutz was referring to remedies such as higher Medicare reimbursement for Hawaii doctors and exempting group and private practice physicians from the state general excise tax.

“One of the things we can do here to really help is pass GET reform,” said Grosskreutz. “We’ve had a number of candidates from both parties that are supportive of the idea.”

To see the Oahu presentation with Grosskreutz and Winkler, click on the video below. To read the full Hawaii Tribune-Herald report on the Hawaii island event, go here. To see the three TikTok videos, go here, here and here.

9-28-22 Hawaii’s “doctor shortage” Oahu event with Scott Grosskreutz and James Winkler

Keliʻi Akina: Over the last several years, we’ve seen dramatic changes here in the state of Hawaii. In fact, two and a half years ago, the world changed with the COVID-19 pandemic. As a result, governments began shutting down economies at every level. Hawaii’s economy was shut down, and suddenly an issue that had been here for a long time came to a crisis point, and that’s the perennial shortage of doctors and medical personnel.

At times, people said that this was being caused by the pandemic, which wasn’t quite accurate. The pandemic certainly was a stress test, but the issues had existed long before the pandemic. 

The Grassroot Institute of Hawaii has been pointing out that for many years, we simply haven’t had the medical facilities nor the personnel to meet the needs of our population. In 2019, for example, we were short of at least 820 doctors. This year, that figure has exceeded a thousand, and it’s growing.

The Big Island has 300 doctors fewer than it needs. So every one of us knows stories of people on the Big Island who wait for months to see a specialist, and have to fly to Honolulu, or perhaps to the mainland, and that’s starting to happen to many residents of Honolulu as well. This really shouldn’t be the case.

So what really is the problem? We’re going to learn that today from two people who know this issue like the back of their hands.

I’m so glad to welcome back to the Grassroot Institute, Dr. Scott Grosskreutz. We’ve worked with him in the past in terms of collaborating on understanding this issue, as well as panels that we’ve done together. In fact, he was with me yesterday on the island of Maui as we spoke to a large group of individuals in the community about the same issue. 

Dr. Grosskreutz is a diagnostic radiology specialist, and he’s the founder of the Hawaii Physician Shortage Crisis Task Force. Please welcome to Grassroot Institute today, Dr. Scott Grosskreutz. Scott, aloha.

[applause]

Thank you for being with us. Let me give you an opportunity to say hello.

Scott Grosskreutz: Just want to say hi to everybody this morning. I also appreciate getting a chance to meet you briefly, as we’ve had lunch here today. I want to thank everybody that’s here. A lot of you are healthcare providers, fellow veterans and folks involved in policy and legislative issues here in the state. And so, thank you so much for being with us.

And Our Shortage Crisis Task Force is not just for physicians. We have nurses, APRNs [advanced practice registered nurses], PAs [physician assistants] that belong in this. Really, the entire healthcare community works together as a team, and we’re facing critical losses in almost every aspect of our healthcare team. 

Jim took a look at our slide here showing the graphic of the heartbeat and was just kind of asking, maybe we shouldn’t see the right-hand side go off into VFib [ventricular fibrillation[, because I think that’s where we’re at right now.

Akina: I was going to say funny, but it’s too tragic to be that funny. But thank you very much. Let’s give another hand and welcome Scott Grosskreutz.

[applause]

I’m so glad today to meet, for the first time, Dr. James Winkler. Although I’ve known of his work on the island of Kauai — and he got on a plane this morning and came over here, so I appreciate that. 

Dr. Winkler is the founder and CEO of Kauai Community Health Alliance, and a member of the Hawaii Physician Shortage Crisis Task Force. He also has a clinic at Hale Lea Medical Clinic, which is on the North Shore, I believe, of Kauai. 

You understand the theory and the practice of your profession, and I want to welcome you here today. Let’s give a hand to Dr. James Winkler.

[applause]

I’ll let you say some welcoming words.

James Winkler: Well, thank you. It’s actually an honor to be here. I’ve taken care of the Kauai community on the North Shore — about five different communities — for over 25 years. We struggled, became a nonprofit in 2008 — because that’s how far back the struggle goes — and we’re almost ready to close our doors. 

So I’m sort of here to put a face — on the boots, on the ground medical care, on the rural parts of Hawaii, the neighbor islands, which of course are just a metaphor for all the rural areas on all the islands in Hawaii. 

So I really appreciate the opportunity to talk to all of you who have a genuine interest in preserving our well-being here in the Hawaiian Islands, and how everything else flows from our healthcare system. So I hope we can all work together in that regard. Thank you for inviting me.

Akina: Thank you, Dr. Winkler. Glad you’re here.

[applause]

I’m going to pose a few questions to our panelists in just a moment, but I want you to get ready because we want to hear from you. There’s a microphone right up here that you can use to ask any questions that you have. So I’ll try to wrap up in the next 20, 25 minutes, and then after that, feel free to come to the microphone and ask or share whatever you would like to do. 

It’s important for this conversation to take place, and it’s important for us to take this conversation to our policymakers here in the state. 

Let me begin with Dr. Winkler. One of the things, Jim, that I have seen with our medical professionals in Hawaii, especially during the COVID-19 pandemic, is rising rates of burnout. There are lots of stories of doctors who’ve actually up and left, as well as other medical professionals, during this period of time, and for those who have been here, there are high stress levels they’ve gone through. 

You’ve probably seen far more of this than I have, really, on the ground level, perhaps at your clinic, Hale Lea Medical Clinic on the North Shore of Kauai. Could you address this? What are medical professionals, as people, going through now with the shortage, and what did they go through during the pandemic?

Winkler: Well, we’re exhausted. We’re depleted. COVID, as you pointed out, really was a stress test. The problem has been going back for decades. It’s very hard to recruit physicians here and physical therapists and all healthcare professionals, and once we do get lucky enough to get one, it’s very hard to retain them. 

We’re exhausted and we’re broke. I haven’t taken a salary in four months just to keep the facility going. So I wouldn’t blame COVID; it’s a very deeply rooted problem in our high cost of living, our high cost of housing and our incredibly low reimbursement structure from Medicare, from private insurance companies, and from Medicaid, Quest. Government insurance now makes up 50% of our population. So we just can’t survive anymore.

And in a way, our facility is a canary in the coal mine, but we’re one of many canaries. There are canaries dropping out every day. We’ve lost 25% of our private practices in Hawaii in the last two years. I mean, just think about that for a second: 25% of private practices have disappeared in the last two years.

So, yeah, I would just broaden the response to be a little more than COVID. It’s deep-seated.

Akina: Thank you. Thank you very much, Jim.

Scott, you have looked at this in terms of the numbers, and in terms of the medical profession as an industry. Your organization, the Physician Shortage Crisis Task Force, has been trying to sound the alarm for many years to let our government leaders know we have a shortage of healthcare professionals, but some of that has fallen on deaf ears. 

What is it that you’re actually trying to say? How bad is this crisis right now?

Dr. Grosskreutz: Well, things are pretty bad, and they’re getting worse. And Joe [Kent], I wonder if I could trouble you just to advance our slides here for us. But we’ve had a documented shortage of healthcare workers going on for many years now. We’ll be displaying an AHEP

] from the Area Health Education Center from the University of Hawaii here. And OK, that was not working.

Akina: There you go. We’ve got that slide up there.

Grosskreutz: All right. Anyway, this [news clipping displayed on the slide] is just talking about Jim’s clinic, and the fact that, you know, it’s on the front page of the paper. We’ve had other front page articles, and some of the other neighbor islands, like the Hilo Community Surgery Center, is threatened with closure. 

There’s just some of Jim’s staff. There’s Jim when he wasn’t quite as long in the tooth, there, over on the right-hand side, just to show how many years he’s been here, and some of his staff.

And here’s that slide from the University of Hawaii showing the worsening shortage of physicians at a time when the population is aging in the state of Hawaii. Now, obviously, as we all get older, we need more care, and that’s one of the reasons that we’ve got a critical shortage of healthcare providers. 

I served as chief of the medical staff at Hilo Medical Center years ago, and I’ve just watched this crisis get worse year after year after year, and in the past, spent a lot of time trying to work with the multidisciplinary approaches on how to provide the best medical care we could in Hawaii. 

Now we’re at the point we’re just trying to have enough providers to provide any level of medical care, and that’s kind of a tragedy.

In addition to the shortage of providers, we also have the second oldest cohort  of healthcare workers in the country. The oldest is New Mexico. They had a general excise regressive tax, much like a GET, and it basically prevented a whole generation of providers from entering that state. 

But we’re second, and we have 37% of our providers over age 60. Statewide, 25% of us, including myself, are over age 65, and [on] the Big Island, a third of us are over age 65. A lot of these providers are working 60, 70 hours a week. And at some point, we’re going to be gone, and we desperately need to bring in new and younger providers to replace us.

This is serious enough that the CEO of the Healthcare Association of Hawaii, several weeks ago, was asking for a declaration of emergency from the state of Hawaii because he said we did not have enough doctors and nurses to staff Hawaii’s hospitals. And the governor responded by waiving some licensing requirements for nurses to bring folks in from the mainland.

And as you can see there [on the next slide], Gov. Ige said this was needed to address an immediate peril to public health. 

So here [next slide]we have the people in charge of our hospital systems, and our governor, all stating that really we’re in dire straits. [U.S.] Rep. Ed Case and [U.S.] Sen. [Brian] Schatz have been very vocal about this.

This was a screenshot from a keynote address that Rep. Case gave at the Healthcare Summit in 2020, in which he described how severe things were. And he went so far to say that Medicare reimbursements for the state of Kauai were a crime, because they were so low that they were less than the cost of providing services often. And that made it very precarious to try to practice in the state of Hawaii. 

To make things more concerned, here [next slide] is an American Medical Association study that found that about 20% of docs and 40% of nurses are talking about retiring in the next two years. Our healthcare workforce is, unfortunately, fairly crispy and burnt out after the COVID pandemic.

And to try to describe this, it was a statewide survey that was done recently, and they found that half of the providers in the state of Hawaii were thinking of either retiring, moving to the mainland, quitting practice, or cutting hours. So that just shows how much worse things are getting. Thank you.

Akina: Well, thank you, Doctor. You know, this is not just a numbers issue; it’s something that you shared, Dr. Winkler, earlier, it affects the very livelihoods of medical professionals themselves. 

Could you talk a little bit more about something you mentioned? You said we’ve seen the loss of physicians in private practice. What are some of the difficulties, financially and business-wise, for physicians who are trying to operate their practices?

Winkler: Well, if I could, before answering that, I’d like to respond to your first statement, which is how hard this is for medical providers and personnel. It’s really not about medical providers and personnel. It’s about people we take care of. 

Akina: Yes. 

Winkler: It’s heartbreaking to not be able to take care of the patients we take care of. In rural Hawaii, in my case, Kauai, we are an outpost on an outpost island. We have no endocrinologist, we have no outpatient neurologist, we have no oncologist. We don’t have a psychiatrist on our island. We have no geriatrics. We have no palliative care medicine. Our ophthalmologist won’t see Quest patients. 

I just had a patient with senile macular degeneration and diabetes, and I tried to get them into an ophthalmologist, and they told me, “Send this person to Costco.”

So the human face of this is profound. These are patients who are depressed, suicidal, have breast cancer, ovarian cancer, diabetes, hypertension. These are our aunties and uncles. These are our children. The loss of a facility like ours is a human crime. So anyway, I just wanted to set the record straight, about it’s really not about us.

Akina: Absolutely.

Winkler: Why is it hard to retain and recruit? What are the financial obstacles? Well, you just can’t pay people enough to live here. It really is that simple. Everything I say after that sentence is just an embellishment. 

Medicare reimbursement in the state of Hawaii is the lowest in the United States. Some of you may not know that Medicare doesn’t pay the same for the same procedure to every medical group all over the country.

It’s kind of a scrum in Congress at the U.S. level. It’s a fixed sum of money, and Hawaii has always lost the battle and come in last. 

Of the procedures that we do, they get 50% more for the same procedure in Alaska. They get more money in rural Alabama for doing the same thing we do here. That’s Medicare. Medicaid pays worse than Medicare. Private insurance companies link their insurance to their reimbursements to Medicare. 

So we simply don’t have enough money to recruit or retain physicians. The physicians that work for me work for 50% to 70% below their mainland salaries — not 70% of, 70% below. 

They’re so dedicated. They’re so dedicated to providing community health, but they just, I don’t know, they don’t last — because they can’t find housing that’s affordable; just the cost of living to bring someone in from the mainland. They have relocation costs. There’s limited jobs for their partners to work when they come to an outer island. They’re away from their family network. And then they can’t be paid a salary that’s a livable wage. I don’t mean enough to buy a Porsche; I mean a livable wage.

So all these obstacles are causing the collapse of our medical system. We survive by generous donations from our community, which we’re running out of, because they’re getting tired of us asking. If it weren’t for those donations, we would’ve closed. 

Just to let you know the services we provide, we provide not only family practice primary care, we provide urgent care. That means, you know, you get a laceration and need some stitches or you wake up throwing up. We also provide physical therapy services. We have three physical therapists. We have four behavioral medicine therapists, mental health services. I mean, if we close, all of that disappears for our community.

Akina: Thank you very much. Dr. Grosskreutz, you and I have discussed the fact that Medicare reimbursements are extremely low for doctors in Hawaii. It’s something that was pointed out by Dr. Winkler. But in your understanding, you believe they’re actually going to become lower as we go forward into the future. I wonder if you could address that briefly, because I have another question for you.

Grosskreutz: Yes. So the rates of Medicare reimbursements are near the bottom. CMS, the Center for Medicare and Medicaid Services, treats Hawaii as a rural agricultural state. So we’re basically at the baseline, and then on top of that, the Hawaii general excise tax is waged on top of that. 

And so a lot of providers, they’re actually losing money, providing medical care for Medicaid and Medicare patients. And then the state of Hawaii comes and taxes you despite the fact you’re losing money on that, and that just aggravates it. And as a result of that, we’re in a position where we have the least number of people that are available to take care of Medicare patients in the United States — behind all other 49 states and the District of Columbia.

To give an example of how negatively impactful this is, this is a tax on patients. Hawaii’s only one of two states in America that taxes patients for being sick or injured. 

So if your child developed leukemia, or you have a heart attack and you’ve got hundreds of thousands of dollars of medical bills and the state’s charging 4.7% on that, and you’ve got a private insurance company, you could have a bill of tens of thousands of dollars. And often, if you have a heart attack or something bad happens to you, you can’t work, and you can’t pay your bills. so that’s just a very, very regressive type of taxation.

Hawaii is the only state in America that taxes Medicare, Medicaid and Tricare, and that has a big effect on all these populations. 

I was talking to a fellow veteran here and talking about how that impacts things, is we have fewer providers to take care of those folks, and what this ends up doing is that we’ve got about 20% of our state on Medicare, we have 30% on Medicaid, and when you add in Tricare, that’s over half of our population where providers are trying to care for where they’re basically breaking even, losing money, and then they’re being taxed on top of that, driving them into the red. 

So those are just some of the extreme problems we have.

And to make things a little bit more challenging, the state of Hawaii actually says that the tax level of the Department of Taxation that the physicians can pass the GET onto Medicare patients — that’s forbidden by Medicare. We’ve been warned that any physician or provider that does that will be investigated by the Office of the Inspector General for Medicare fraud. So we can’t afford to have our providers follow the recommendations of the Hawaii Department of Taxation because we can’t afford to lose anyone else.

And President of the Hawaii Tax Foundation Tom Yamachika, described that as the providers being between a rock and a hard place.

Akina: Absolutely. And many of you know that at the Grassroot Institute, we work with Tom Yamachika, who’s a fellow here, an expert in taxation for us. 

And one of the things that we have been calling upon the state to do for many, many years is a best practice growing across the country, and that is to stop applying the GET, the GE tax, to medical services and to food. 

It’s a regressive tax. It hurts those at the lowest level of the income ladder, and it also has repercussions, as our panelists have shared today, in making it very difficult for physicians who are operating with an extremely low margin to be able to survive and make a living. 

In addition to that, we have tried to popularize this idea — and I’m very pleased that during the current election season, during the primary election in particular, several candidates for office have adopted that platfor, to call upon the government to say that, if they get elected, that they will work toward removing the GET from food and medicine.

Now, back to our panelists, a survey was conducted recently called the Access to Care Survey. Could you share some of the results that you found?

Grosskreutz: Yes, we’ll be happy to do that. And just to put a cap on this last point, Keliʻi, this is a survey of larger medical practices across the United States that was carried out [next slide], and 92% of practices stated that at current Medicare rates in the United States in 2022, that 92% of them are losing money providing care for Medicare patients. And basically, they’re talking about other cuts of 8.5% next year at a time when inflation is 8% to 10%. 

And so, there’s the consequences that these clinics are thinking about, faced with these urgent, these severe cuts, we’re cutting back on staff, letting their clinics close and having to fire employees, which would be tragic.

So here’s the results of the Access to Care Survey [next slide]. This was performed by the Hawaii Rural Health Association and Community First, which is a private organization on the Big Island of Hawaii. And really, a lot of these results are just really appalling, where we’ve got six in 10 people stating that they’re having delays in seeking care, and about 25% of the time, those delays are severe. 

And things are bad enough that often people just don’t seek care, particularly during COVID. If you’re on the Big Island or Kauai, and you’ve got to fly to Oahu, that was almost impossible and very expensive, so people don’t seek care.

And just as a counterpoint to this slide, a breast cancer specialist, and I see people walking into our clinic literally every week with advanced breast cancer palpable masses and axillary adenopathy. A lot of them are younger. A lot of them were not screened during the COVID times because of the lockdowns. And this is just a tragedy. We have a hard time trying to help these people at this advanced stage of the disease. There’s only so much we can do.

And another thing that’s really kind of scary here, is people in the survey [next slide] said that because of their economic situation, 52% of them have been cutting back on grocery and food purchases, to back up the professor’s point here about how important that is.

And the GET is a pyramid tax. So if you’re growing a crop and you sell to a wholesaler, you pay the GET. If the wholesaler sells it to a processor to package it, and sells it to the grocery store and Safeway, you pay the GET. When Safeway sells it to you, you pay the get. That’s four GETs on a single purchase. 

It was like 36% of people [next slide] said that they had delayed or deferred medical care because they couldn’t afford it, which is a tragedy.

The other thing that’s really of concern is the number of people that feel that because they can’t afford care —  I’m going to back up here just a bit — that they can’t afford to live in Hawaii. 

And since this was outpatient migration, [next slide] now the professor and Joe Kent have been talking about trying to educate us about the number of people who are leaving the state of Hawaii, and reportedly 12,600 left last year, and we’ve been losing population since 2016. And many of them are younger people that we need to stay in our state, that have marketable skills. Many of them are healthcare providers. 

But here [next slide] you see the amazing statistic that 20% of people are thinking of leaving the state of Hawaii because they can’t access healthcare. I mean, that’s just a tragedy.

On Maui, it’s as high as 33% of the population is thinking of maybe having to leave the state to find care for themselves and their families. And it’s almost hard to describe the impact that that’s going to have on our communities.

Akina: That’s staggering. Now, one of the problems that prevents us from getting the medical care we need here in Hawaii is the regulatory climate in which doctors and hospitals and any medical providers have to operate. 

One of the features of Hawaii’s regulatory climate is what we call the certificate-of-need laws. Certificate of needs, C-O-N, require that whenever a hospital is going to be built, or a clinic opened, or a dialysis unit added, or beds moved around significantly within a hospital to increase their number and so forth, whenever that happens, the party that wants to bring that about needs to go before a board.

The problem with this board that would grant the certificate of need is that it is comprised of the competition to the hospital. In other words, if you want to open up a hamburger store on the corner, you would have to go before a commission made up of McDonald’s and Burger King and Jack in the Box, and they would be the ones who determine whether there was need for another hamburger stand.

Now, I’ve traveled across the islands, and I can tell you, on every one of the neighbor islands, this has been a problem that has prevented the development of medical facilities that are needed.

I wanted to ask, Doctors, if either of you has any firsthand or accounts of how this impacts the practice of medicine in your areas?

Grosskreutz: I had helped our radiology group years ago when I was the president to put in an application, bought an outpatient MRI unit, which we needed. It was a process that took years, and even with almost unanimous community support, there was resistance from hospitals and others that already had different types of units that weren’t the same type of service that opposed that.

And you can spend tens of thousands of dollars on that. Once you do get the C-O-N in Hawaii, it can often take years — as anyone who’s tried to build the new facility in Hawaii knows this. They had a recent article in the paper a few months ago about how the delay in terms of getting a building permit in Hawaii was several years longer than elsewhere.

And just to point out how absurd this whole process can be, one of our task force members runs a primary care clinic in North Kohala on the Big Island, and they said that they didn’t have enough space in their clinic to see all their patients. They flew in a modular space that was basically to be used as an office, and this was being used throughout the United States, and they tried for two years to get that permitted by the County of Hawaii and they couldn’t do it. so They flew out this modular unit to treat more patients and they couldn’t use it for two years, and they finally just got rid of it.

Akina: That’s astounding. Hard to believe, but it’s taking place. This is one of the reasons that Grassroot Institute will continue to advocate for modifying our certificate-of-need laws. It’s very necessary. and it’s also a best practice as we survey what’s going on in states around the country. States are abandoning this because they’re trying to meet their needs.

Another problem we have, in terms of gaining access to healthcare, has been the slowness of Hawaii to respond to modern technologies such as telehealth. Prior to the pandemic, it was pretty restrictive and now, after the pandemic, or because of the pandemic, the emergency decrees had to allow telehealth. And as you pointed out, Dr. Grosskreutz, Gov. Ige is open to that now.

What solutions, including telehealth, do you see? I want to start with you, Dr. Winkler, what can we do? Let’s turn a corner here and start talking about changes to our system that could really help us to solve this problem of healthcare shortage.

Winkler: So you’re not asking me specifically about telehealth?

Akina: Well, you can respond to that as well.

Winkler: Well, telehealth is an important part of medical care. It’s difficult on rural islands because our internet system is so poor. A lot of people just don’t have access to good-quality connections. And when we try to do telehealth, they constantly disappear on the computer. But that said, that’s a problem of rural neighbor islands in general. 

But the concept of telehealth is critically important for delivery of healthcare, as long as it’s reimbursed at the same rates or higher than regular visits, because the use of our resources is the same. In fact, it takes longer to bring a patient in through a telehealth visit because you have to establish an internet connection, and oftentimes elderly folks are less savvy with that, or their phones aren’t working, or they didn’t give permission for the software to access it and on and on, and then once they’re in, it’s the same amount of time spent with their provider, and then checking out and then making a new appointment. 

And then, frequently, insurance companies will pay less for a telehealth visit, even though the utilization of resources is the same. So as long as they’re willing to keep paying for it, it’s a valuable part of the work we do.

Solutions. Well, the GET tax is an important one. Taxing medical care is criminal. What Scott was saying — just to reiterate in case it wasn’t clear — when you go buy an ice cream cone, you get charged 4.127% extra to cover the GET tax on the cost of your ice cream cone. Medical clinics can’t do that. It’s illegal. So we actually pay the tax on our patients’ services for Medicare and Medicaid. So that’s one thing.

Another is low reimbursement. That can be corrected in many ways. The Legislature has the ability to raise Medicare reimbursements. It’d be a leveraged investment because the federal government will pay 50%. 

So if the Legislature said, let’s increase Medicare reimbursement by $400 million a year, it would cost $200 million, because the federal government would pay $200 million. By increasing Medicaid reimbursement, that would take a huge burden off of the medical industry.

Private insurance companies. The insurance commission and the Legislature has to hold them accountable. Typically, private insurance companies like HMSA, HMAA, UHA, Kaiser, etc., in the United States, the average is they pay Medicare plus 30%. In Hawaii, our clinic receives Medicare minus 20%. 

I already explained how low Medicare is. Why is that? HMSA collects $3.8 billion a year in premiums. They have assets of almost $2 billion. They’re not hurting. We’re hurting. The public is hurting. So how does that get fixed? 

The insurance commission has to do its due diligence and hold the private insurance companies accountable. 

Increasing Medicare rates — we can all lobby our federal, Congress and senators to work to make that happen. That’s a federal issue. So those are the big three.

And then the last one, I’d say, is housing. Housing. There’s no way we solve this recruitment and retainment problem without a creative housing solution. 

I won’t go into details on that, but there are ways of doing equity-sharing. Very briefly, in 1980s, we had a huge housing crisis in California, and Stanford couldn’t hire professors because they couldn’t afford to live there. 

So Stanford was like, “Well, you know, I think we can fix this. We can share the equity of the houses that our professors live in. So how about if we pay 40% and the professor pays 60%, and we have shared equity? We know we have a good tenant. Hell, we’re paying their salary, so we know they’re going to pay their rent. 

“And then if they have money and they want to buy our 40%, fine. If they move, we give the remaining 60% to someone else. Meantime, our investment in that 40% increases; we make money.” 

It took Stanford about an hour and a half to figure out that was a good job. They now do that in New York; Waco, Texas; D.C. It’s called equity sharing. There are many ways to do it.

And then if our leadership would free up state land, then that land could be used to do this equity-sharing and this could be done by anyone that had assets: banks, insurance companies, jobs, university, medical school. Anyone that has assets can trans–,  usually they have, they’re holding real estate assets anyway. 

So these real estate assets could be used for housing at all different income levels to help our nursing staff and our medical providers and all the rest.  

So, to summarize: GET tax, housing and reimbursement at all those levels that I spoke about.

Akina: Thanks, and Dr. Winkler, I appreciate the fact that you have looked at two different areas where we can find solutions: the regulatory climate that controls the practice of medicine, but also the economy itself. Doctors, new doctors, all medical people and so forth live in an economy where housing has to be affordable. and that’s a place to start. 

I want to switch to Dr. Grosskreutz here and ask you to address a couple of other possible solutions. One came as a silver lining during the emergency decree that was repeated several times during the pandemic.

And that is, we found that we couldn’t, at the front end of the pandemic, use medical personnel from out of state because we have such strict licensing laws, that although we have fully educated and licensed medical personnel in a number of fields who wanted to come and practice, they couldn’t, because our law prevented that. So the silver lining is that during the emergency, we lifted those restrictions. 

What can we learn about lifting those restrictions permanently perhaps, and any other solutions you may have with respect to how we can solve our healthcare crisis?

Grosskreutz: Well, that was a solution that played a role at a time where we didn’t have enough staff to cover our hospitals. And the interstate licensing restrictions, they can be and should be standardized. And sometimes states will have a coalition where if you could practice in this group of states, you can also practice in other groups of states. That could make a lot of sense. 

One of our dental colleagues here, I hope you can talk to about his experience here recently, he was sharing how he was trying to get licensed in the state of Hawaii when he has been practicing over 40 years in other locations and things like that.

But these barriers are very, they’re not helpful to the state of Hawaii. They’re not helpful for us to keep our staff. 

And the other thing that’s going to be a problem is that it’s not like there’s a lot of other healthcare providers elsewhere in the country to recruit from. The Association of American Medical Colleges estimates that there will be a shortage of as many as 139,000 physicians over the next decade in the United States. And the American Nursing Association projected that there was a need for another 1.1 million nurses in 2022.

So every state’s having the same problem we are. And what most states are trying to do is trying to be as attractive as possible and creative as possible to bring more healthcare providers into their state. 

You know, in Hawaii, unfortunately, we seem to be focused on almost chasing away as many of our providers as we can. I mean, the purpose of taxes for governments, one is, of course, to raise revenue, but the other is to encourage or discourage economic activities. 

That’s why governments put what they call sin taxes on alcohol and tobacco, because you don’t want people to use that. Well, in the state of Hawaii, we actually have a sin tax on caring for Medicare and Medicaid and Tricare patients. [chuckles] So try to make some sense of that.

In terms of the idea of trying to train more people locally, that makes a great deal of sense. Here’s just a headline with Gov. Ige acknowledging that that’s something that’s badly needed in the state here, to train and recruit and retain our local folks. 

But If we do that, and even if we say we’re going to cover your medical school loans if you stay in your practice, they have to be viable in the long run or they’ll stay for a number of years till they pay off their loans and they’ll leave just out of necessity.

The average person getting done with medical school and training is a quarter million in debt, sometimes as much as half a million in debt. 

My daughter is a mohs surgeon. She’s a dermatologist training to be a skin cancer surgeon in fellowship, and her husband is a surgeon. Between the two of them, they’re $400,000 in debt. 

I mean, if they came back to Hawaii, they would have a very difficult time in private practice trying to basically decide whether to pay your medical loans or pay for a house. There would be no room left over in their budget to pay for a clinic and staff.

Akina: Thank you. I’m sure you have much more to share, and I hope that our audience will be able to parse that out of you because we’re going to go to our audience now and invite all of you to consider asking a question or sharing something. 

We have a microphone that is set up here. If you’d be so kind to come up to the front, to the microphone and introduce yourself and concisely ask your question, we’d appreciate that. And as people make their way to the microphone, let’s give a hand to our panelists, who’ve already shared just tremendous information. Thank you so much.

[applause]

We appreciate that greatly. Thank you. 

David, go ahead and introduce yourself and go ahead and ask your question.

David Hardy: I’m David Hardy, 42-year resident of Waikiki, from Colorado. and this is a very serious subject. I’m going to ask a very serious question. Dr. Winkler, have you considered asking the Fonz, your brother, to come in and help us out?

Winkler: I am the Fonz.

[laughter]

Hardy: Thank you very much.

Akina: Thank you, David. Professor Kate Zhou from the University of Hawaii.

Kate Zhou: Thank you so much. I really appreciate, especially the solutions. I can offer two solutions. I’ve been working with Dr. Akina to do some education in China. I was thinking about, in Taiwan, Hong Kong, India and China, can provide first-grade doctors and nurses to come [to] Hawaii. We can make Hawaii [the] Asia-Pacific center for medical trainers, so that when they come here we do basic training, improve their things, and their job is they have to serve in rural community Hawaii for five years before we can give them permanent residence. So in this way, we can, using our Hawaii whatever, we need the federal government giving them a special student visa or something like that.

So I think that’s possible. We can make so that other states will pay your center for Hawaii shortages to borrow our traveling doctors and nurses.

The second solution is to use UH [University of Hawaii], especially community college, both at Kauai and Maui, Big Island, and then also KCC Kapiolani Community College] and LCC [Leeward Community College[, to train nurses from India, China, Philippines to do short term, mostly English. They have very good nurses. 

So in this way, we can really solve not only nurses in Hawaii, but also in rural areas across the United States, but the federal government will pay Hawaii, pay your center for the training and for the traveling nurses and doctors. Thank you.

Akina: Thank you, Dr. Zhou. Appreciate that comment. Anyone care to respond to that?

Grosskreutz: Yeah. I think that’s a wonderful idea. I think the experience has been — and we have a family practice branch from the University of Hawaii that we help train their residents — is that if people come to the neighbor islands and they work there and they live there, they’re much more likely to stay long term than if they were to, say, come from someplace else and not have that experience of having their training locally in the island. So thank you so much for that proposal. It’s most welcome.

Akina: Thank you very much.

Zhou: The university can be a very good place for people to pass like this.

Akina: We’re always open to participating with you, Dr. Zhou. Thank you. Kate Zhou is one of our scholars at the Grassroot Institute. We appreciate all of her work. 

Kindly introduce yourself and ask your question.

Kimberly Kopetseg: My name is Kimberly Kopetseg. I’m a family nurse practitioner that has worked in critical areas for the last 22 years of my life here in Hawaii, protecting, serving, and saving lives of our community. 

I ran three of our ER’s night shift as a charge nurse. I’ve done neurosurgery on the brain and spine. I’ve worked as a family nurse practitioner at Schofield in our only acute care clinic as a civilian. I’ve worked in other areas on our island.

As we know, there’s lots of issues with shortages. As an emergency room nurse, we were always short-handed. While we’re isolated islands here in the middle of an ocean, there’s not a lot of staff to choose from. 

With that being said, we have to hire traveling nurses. They come because it’s Hawaii, it’s a vacation. They make a lot more money than us. They’re here temporary to enjoy it and then move on. 

As they’ve mentioned already, there’s lots of issues that need to be addressed that haven’t been addressed.

I am also running now as a House Representative for District 44 on the west side. I have tried to address my concerns with Lieutenant Governor, Dr. Josh Green, who continues to silence me at different meetings, where I pay for a meal, and different areas. I have been silenced, not been able to get a meeting at the Department of Health, our Department of Education. 

As a nurse practitioner in a private setting with neurosurgery, the surgeon that I worked for had to pick and choose who we got to do surgery on. That broke my heart. He had to do it to be able to survive here because of the issues with Medicare, Medicaid and Tricare. We would take Tricare at times. That shouldn’t be the case at all.

As a healthcare provider in different settings, when I wanted to prescribe medications, I was denied being able to give that to my patient. I had to call and the patient had to jump through hoops. They tried X, Y, Z before I could prescribe. 

They’ve taken away my knowledge, my expertise, my skills as a healthcare provider. The insurance company is telling us what to do and how to practice medicine. 

As a provider, that is not acceptable to me. That needs to be changed. Our medical insurances shouldn’t be making judgment calls.

For us to do surgery on the brain and spine, I had to call a doctor when my patient was denied to be able to get surgery that was medically necessary for this patient. I would have to call up, schedule time out of my time from seeing patients to have these meetings and this conversation on the phone. 

I would have to speak to a doctor, who wasn’t even a specialist at performing the same type of surgery I am, and I have to get approval from a person that didn’t even know what I was talking about. 

There’s lots of changes that need to take place.

I’m hoping when people vote here in our general election, that they’re going to look for new faces with fresh ideas. There’s a lot of issues with our housing, with our affordable housing. First, tourists [are] keeping us afloat. Then our middle class, we all have to work to take care of everybody. They’re all leaving to the mainland because they can’t afford to survive here. 

I’ve talked to developers. I’m out in our community talking to a lot of different people. I’m even talking to the homeless. We have a lot of homeless here because they lost their jobs during COVID. They’re not wanting to be homeless, but they can’t afford to live in housing, so they’re living in tents with their families. This is not acceptable.

Akina: Well, thank you. You’ve made some very good points, and I appreciate it. Would you just repeat your name?

Kopetseg: Kimberly Kopetseg.

Akina: Thank you very much, Kimberly. 

Anyone else? This issue has clearly touched a nerve, and it’s something that we really must make a priority of in our state. Thank you, sir.

MARK HAS READ TO HERE 47:43

Russell Wong: I’m Dr. Russell Wong. I practice in Big Island, Maui, Oahu and Kauai. I don’t know if people know who I was. In 2019, Queens fired my group, all local workers, they fired my group and took it over. 

And I’m just talking about something a little different. We’re talking about rural care, but I’m just going to tell you, there’s a crisis that’s coming on because of Queens and HPH [Hawaii Pacific Health]. And the issue is, I’m a private practitioner and I’ve left Hawaii to do my private practice because I refuse to work at Queens and HPH.

But I’m just going to tell you, the crisis that’s going to come forward is Queens and HPH are hiring all their physicians. So most of the Queens is, there’s Maui, which is Kauai. There’s Queens, which is with North Hawaii, West and Punchbowl. Sounds like they’re going to take over Wahiawa. They’re doing a meeting together. and HPH has Wilcox, Pali Momi, and Kapiolani. The point is, they’re hiring all the physicians.

And I’ll tell you, if you talk to physicians, all the private practitioners are being driven out of town. I was the first group that got fired by them. And I won’t go into details of how disrespectful and how I don’t trust HPH or Queens to do anything at the mid-level management level. I don’t talk to Ray Vara [HPH CEO] or Dr. Green. 

But I’m just telling you, you’re going to find out in the future the problem of not having enough physicians. It’s going to get way worse because they’re hiring doctors and they’re all leaving in two years.

Akina: Thank you very much.

Wong: Everybody should watch out for that. I’ll tell you the solution. I actually have two business degrees. I have an MBA from UCLA and a medical health-management degree from Harvard. The only solution is going to be through the Legislature because Queens and HPH will not do anything for the population. And you need business people or people who are business-savvy to come up with solutions. Because it won’t be from Queens or HPH.

Akina: Thank you, Russell. Appreciate your insight. It reflects what our panelists are saying.

Grosskreutz: Professor, could I —

Akina: Absolutely, please. In fact, I was going to refer to what you were saying. If you take it now and respond to that.

Grosskreutz: I want to thank our fellow healthcare providers for their comments today. And the whole issue with preauthorization is a huge issue with everyone that’s on our task force and providers throughout. 

As Kimberly has pointed out, it basically is stripping away the ability of your provider, your physician, your AP [assistant physician] and your PA [physician associate] to make decisions for you, where basically, every diagnostic decision, every therapeutic decision, physical therapy, whatever it is, is second-guessed by insurance companies.

And in a perfect world, the perfect financial setting for an insurance company would have everybody in the population on the insurance plan and no dollars spent on healthcare. So that’s just a natural conflict of interest, you know, in terms of trying to suppress the level of care that providers think is appropriate. 

Who would you rather make these decisions? Your provider that you’re seeing, that’s known you for years and is fully familiar with all your problems, or somebody that’s sitting in a vendor’s office, you know, somewhere in New Jersey? And that’s a real problem.

The other issue that we have is, really private practice comprises the bulk of the care on the neighbor islands. and the hospital-employed physician system, it is important that we have those positions there, but the hospitals and their employed staff are not subject to the general excise tax. 

In fact, the Healthcare Association of Hawaii said if the general excise tax was applied to Hawaii’s hospitals, many would have to cut back services or close.

So we’re almost in a position where we’re causing private practice to go extinct in the state of Hawaii. And if we’re planning on doing that, and we’re basically locked in [the] same old, same old, and we can’t change that path, you have to take a look at what happens after the private practitioners are gone. 

I mean a government healthcare system, it could be achieved, but that would take at least a decade to build out. You’re going to see mortality, morbidity go through the roof. And already on the neighbor islands, you’ve got much higher morbidity, mortality for stroke and heart attack and cancer and suicide and infectious disease and everything else you can think of — sometimes significantly higher. So there’s going to be a price for that.

Akina: Thank you, Dr. Grosskreutz. Dr. Winkler, please.

Winkler: I was just going to add that if it seems self-serving to try to protect private practice — which I’m not a private practitioner, I’m a nonprofit community clinic — but we need private practice because we’re a rural setting. 

You can’t put Queen’s Medical Center into a rural setting. So if private practice disappears, you lose access to care. I think that’s the biggest issue for the people of Hawaii.

Akina: Absolutely.

Winkler: And then the administrative burden that Kimberly and Scott were just talking about, you know, having to get prior authorizations for absolutely everything — our medication, prior authorization; CT scan, MRI, prior authorization; physical therapy, prior authorization _ it’s exhausting. 

We have two people we’ve hired just to deal with insurance companies to deal with their prior authorizations. 

So I just want to mention there is a bill that’s in the Legislature in California now to prevent insurance companies from being able to put this administrative, unreimbursed burden onto clinics. So this can be solved legislatively.

Akina: Thank you, Dr. Winkler. There’s certainly the human side in terms of the toll that the healthcare shortage takes, but there’s also the political-economic dimension that we have to see. And this is a great point simply to punctuate that what we’ve heard today is that increased government regulation over an industry, as well as taxation schemes, is ultimately driving out free market choices that people and professionals should have. And that’s fundamentally what’s wrong with this model.

Now, because of the time today, we have only room for one more person to comment or to share or ask a question, and then what we can do is stay here together in the room and you can interact with our panelists. But we are pleased to have another physician. Kindly introduce yourself and share what you have to share.

Krista Kiyosaki Schoppy: Hi, my name is Krista Kiyosaki Schoppy. I am a pediatric ENT surgeon in Hawaii. I returned to the islands three years ago. I’m originally born and raised in Hilo, trained at JABSOM [John A. Burns School of Medicine]. I moved back here with my husband, who is also an ENT [ear, nose, throat] cancer surgeon. and I’m in private practice. 

I came back to Hawaii knowing that the cost of living was high, the reimbursements were low and it was going to be tough for us. That’s not my problem. I see Medicaid, I see Medicare, I see Quest, I see Tricare, I see all those patients because I am here to serve the population of Hawaii, serve the community that raised me.

The problem that I am having is that, again, the big institutions in managed healthcare —  HPH, other healthcare organizations — they’re pushing us out and they’re squeezing us out. And like I said, I came back here three years ago. My husband and I are both subspecialty surgeons. We are committed to being here, but if we can’t make it work, we’re going to leave. 

I just want to know if anybody here has any ideas on what we can do to protect private practice physicians who are really trying.

And I am not trying to make more money or turn a profit; I just want to be able to exist here and practice and serve the community. 

And I’m really kind of at my wit’s end, and I think that the only thing that we have going for us is that we’re young and energetic, and we are really, really trying and we work really hard. But other than that, if this goes on for much longer, the burnout will be real.

Akina: Thank you so very much for sharing that. I hope you’ll stay around and we can all talk a bit more.

Winkler: Keli’i, can I make a comment?

Akina: I would love to let you comment, but allow me to defer that to your closing statement in just a moment. 

Can you see how much is at stake for patients, all of us, and for the medical community themselves? That’s why this conversation is so important. 

I want to say, before I allow my panelists to give a closing comment, I want to say how grateful I am to the members of the medical profession who showed up today. It shows that you are looking for solutions and you’re also part of the solution, and we’re very honored with your presence. 

To all of you who are here, we have to be part of the solution. 

You’ve seen that this is an integrated problem. It can’t be solved with any one little piece. That’s why we have to work at the micro level and the macro level. 

The micro level is to look at the medical industry itself and work hard to get rid of regulations that don’t belong there; to work hard at being able to make it more feasible to recruit new members. 

But at the macro level, we have to also fix the economy. Doctors and medical professionals just can’t live here, you’ve heard, and make a living if we can’t afford housing. Those are important issues that have to be dealt with.

That’s what we work on at the Grassroot Institute, and I want to invite all of you to continue working with us as we prepare for the next legislative session. This will be a major priority for us. 

Now, as we close, I’m deeply appreciative today of our two panelists, Dr. Scott Grosskreutz and Dr. Jim Winkler. And gentlemen, Doctors, I’d appreciate it if you share any closing thoughts that you have with our audience, and then we can interact together after the meeting today. Dr. Winkler?

Winkler: You heard the quiver — I’m sorry, I don’t remember your name — in her voice. That’s the quiver of exhaustion and dedication and wanting to serve your community that you were born and raised in. 

I guess I want to mention the concept of what is a public good. It’s an economic concept. Sunshine is a public good. It’s something that could be enjoyed by everyone simultaneously.

In society, we have a number of public goods, like the fire department, like national defense, like roads and highways. These are things that make society work, and when you have more public good, everything works better. 

Medicine is a public good. It’s sometimes thought of as a bunch of competition, but we all, as Keli’i is saying, have to work together, e hana kākou. If this is not an ecosystem where we’re all giving our all and just putting our personal needs aside, we’re not going to survive.

So if you start to think of medicine and healthcare as a public good, everything will come better from it. Real estate will improve, investment in Hawaii will improve, the business community will improve. And that’s where we can make a list of our stakeholders because we all have a huge stake in healthcare in Hawaii.

Akina: Thank you. Let’s have a hand for Dr. James Winkler. Thank you.

[applause]

Now, Dr. Scott Grosskreutz, any closing thoughts?

Grosskreutz: Well, first, I’d like to thank Grassroot for sponsoring this and all of you for being here today to become part of the solution. This is absolutely a problem that’s been festering for 15 years, and it’s time to take action this year. 

There are certainly things that we can do. Two years ago, we helped draft a bill to exempt physician APRN [advanced practice registered nurses] healthcare services in the state of Hawaii from the general excise tax, and it passed the Senate without a single “no” vote. It’s time to get that bill reintroduced and passed this year.

Our healthcare community, just a lot of dedicated people. We wouldn’t have the best healthcare statistics in terms of longevity and good outcomes in the nation, if we didn’t have a good healthcare team. To watch that wither away is just sad. 

Our healthcare workers, you know, they’re understaffed, they’re overworked, they’re burnt out from COVID, and they’re rapidly aging out. We need to bring in new younger providers.

There’s been some work done by the American Medical Association that [shows that] a physician or healthcare provider in the community can bring in as much as $3 million in economic activity. You can imagine if we could recruit the thousand missing physicians, or the hundreds of missing APRNs and PAs, we could generate billions of extra economic activity and taxes for the state. 

And I’d like to just point out that Mayor Mitch Roth met with our task force and he kind of noted that it’s going to be extremely difficult to recruit new businesses and provide new job opportunities on the Big Island if we continue to see a collapse of the private practice sector. 

So thank you so much for your attention today, and again, thank you, professor Keli’i.

Akina: Thank you so much, Dr. Grosskreutz. Appreciate it so much.

[applause]

What a great panel discussion today. These doctors have given us such insight, and so have many of you who came to the microphone, as well as those of you talking around the table. Mahalo nui loa. Thank you so very much. And another Hawaiian word or phrase which Dr. Winkler used: E hana kākou. Let’s work together. 

I can feel it right now. Can you? That if we work together, we can solve the whole complex of problems that are causing the healthcare shortage.

It’s urgent. We’ve got to do this. Thanks for being part of the conversation. Thanks for being part of the solution. Thanks for being here at Grassroot Institute today. Aloha, everybody. Aloha.

[applause]


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PETITION: Exempt medical services from Hawaii's excise tax!

To the Hawaii Legislature:

Hawaii families face skyrocketing healthcare costs and a shortage of doctors. Exempting medical services from Hawaii’s general excise tax would result in millions of dollars in savings for residents and help bring doctors back.

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