Experts outline how new compact will improve healthcare: Oahu

The decision this year by Hawaii legislators and the governor to join the Interstate Medical Licensure Compact was not only “a practical win for people who are in pain and suffering and who need medical care, but …  also a philosophical win for those who want to celebrate the fact that economic freedom can help people in our society to thrive,” according to Keli‘i Akina, president and CEO of the Grassroot Institute of Hawaii.

The Institute sponsored events on Oahu and Maui in late July that outlined how the compact will work and what benefits Hawaii residents can expect to receive from it. Akina, moderator of  the Oahu event, said its main advantage will be to help relieve the state’s longstanding doctor shortage.

The featured speakers at both events were Marschall Smith, executive director of the Interstate Medical Licensure Compact Commission, and Hawaii interventional radiologist Dr. Elizabeth Ann Ignacio, current chair for public policy and president-elect of the Hawaii Medical Association. Joe Kent, Institute executive vice president, moderated the Maui event.

Smith explained the origins and inner workings of the compact — which has grown to 41 U.S. states and territories since 2017. Ignacio addressed local concerns regarding telemedicine, culturally competent care, behavioral health services and more.

“I’m sure you’re well aware that we have serious problems with our provider recruitment and retention, and we’re very excited about the bill that has passed for the Interstate Medical Licensure Compact,” Ignacio told the Maui audience. 

Put simply, a state’s participation in the IMLC allows licensed doctors who meet the compact’s strict requirements to apply for additional licenses to practice medicine in any other member state without having to go through each state’s individual, often lengthy licensing process. 

“The thing that’s important for you and for Hawaii is now you have a nationwide pool of physicians that you can draw upon,” Smith said to the Maui audience. 

According to Smith, states that have joined the compact see, on average, a 10% to 15% increase in the number of new licenses issued in their states, and about 45% of the physicians that get licenses through the compact do so to provide services in rural and underserved areas. 

“It appears that approximately a quarter of all the new licenses issued in the United States are using the compact process,” he said during the Oahu event. “So it’s safe; it’s effective; it’s quick; physicians like it; [medical] boards like it; and it’s an economic boon to the state.”

To see the Oahu event, click on the image below. A complete transcript follows. To see the Maui event and its accompanying transcript, go here.

7-28-23 IMLC event, Oahu

Keli‘i Akina: Aloha everyone, and welcome to the Grassroot Institute of Hawaii. Great to see you today.

I want to thank you for joining us for a very important topic. Here in Hawaii, we have an abundance of so much: sunshine, beautiful beaches, wonderful culture, glorious people. We are the destination spot for everyone across the planet.

But when we look at our society in depth, we see there are many things for which we have massive shortages. Housing is at the top of that list. As a result, we are in the midst of a six- to 10-year decline in our population because of the cost of living — in large part, due to housing. 

But there’s another shortage we have that doesn’t get talked about quite so much — unless perhaps you or a relative or a loved one feels it — and that’s the medical personnel shortage. I recently was on several neighbor islands — Maui, Molokai, Kauai, Lanai — and one of the things that struck me was the story after story of individuals who couldn’t get the medical care they needed. 

If you live on Oahu, you can drive down to your health maintenance organization — Kaiser, perhaps — or go to Queen’s [Medical Center] with your [Hawaii Medical Service Association] insurance and get a doctor. But even then, it may take a long time to get a specialist; it may take a long time to have an appointment. 

But for many in our rural neighbor islands, it won’t happen on their island. They’ll have to fly off their island for a routine examination, or go to the mainland. And when it comes to getting a specialist, that’s something that just may not happen.

This past year we had two beloved physicians pass away; they serviced 50% of the people on the island of Molokai. I was just there a couple weeks ago. I spoke to a wonderful elder kupuna. She told me that one of her greatest fears is that she won’t be able to die on her island. She’s going to need long-term health care, and there is no facility on her island. 

And there are hundreds of kupuna like her on the island who are not dying with, as she put it, the dignity that they deserve. Because they can’t get the medical care in their own home and have to leave.

There’s a human side to this that sometimes gets missed in the work that we do at Grassroot Institute, which is the policy side, the statistical side. But we do remind ourselves that for every number we look at, there are individuals. 

‘The Hawaii Physician Workforce Assessment Project tells us that there are 776 too few physicians in Hawaii. The Hawaii State Center for Nursing tells us that the state is 400 nurses short. 

As we look at this situation, as a focus of our research and our activism at Grassroot, the problem we see is complex. The shortage is caused by many factors. One is that Hawaii is only one of two states in the country that taxes medical services.

If you look at our 4.0% [General Excise] tax — and higher in terms of what has been added to it recently by counties — it doesn’t sound like a lot. But for a private practice physician on a neighbor island, it’s a huge part of their very small margin. 

Hawaii is also the only state that taxes Medicare and TRICARE services. We also have amongst the lowest Medicaid reimbursement rates in the nation. 

In addition to that, we have a system of “certificate of need” required to qualify for everything from opening up a dialysis clinic to another wing to building a hospital that reportedly, by private practitioners and many community members on the neighbor islands, really doesn’t serve their need. 

When it comes to alternative ways of helping people, our occupational licensing laws are stringent and can take several months. During the pandemic, we had a shortage of ICU beds. We had a shortage of medical personnel. And one of the things that became evident wasn’t that the COVID crisis caused that shortage. It said that shortage was in place already, and the COVID crisis simply made us more aware of it. 

But there’s a light at the end of the tunnel. There are about a dozen things that have to be done, and the first of them was just accomplished. Your Legislature passed an important bill this past legislative session, and it came about because members throughout the community came together, multiple organizations, and worked together — as we like to say at Grassroot Institute, e hana kākou, let’s work together — and the people of Hawaii won. 

We’re pleased today to have two individuals who have been part of this, who have the expertise on the change of law, and who are willing to share with us. You’ll have the opportunity to have a question-and-answer period with them.

But today, it is my privilege to welcome at the Grassroot Institute, Dr. Marschall Smith, who is the executive director for the Interstate Medical Licensure Compact Commission. This organization helps to facilitate the expansion of a program that has served dozens of states by allowing medical physicians from one state to have their credential acknowledged by another state.

That’s something that couldn’t happen in Hawaii. But because of their work, our governor just signed a law that will make it happen as soon as that law gets implemented. But please welcome, from Colorado, Dr. Marschall Smith. Aloha. [Applause] We’re looking forward to your comments, Marschall. 

In addition to Marschall, we have Dr. Elizabeth Ann Ignacio. She’s a physician, and she’s a resident of Maui island, and she practices throughout the state. She’s a fellow of the American College of Radiology and the Society of Interventional Radiology. 

She’s also the statewide interventional radiologist and president elect of the Hawaii Medical Association, whose long campaign for tax and regulatory reform to help improve our healthcare system.

Very proud to introduce one of our own today, Elizabeth Ann Ignacio. Give her a big hand. [Applause] 

I mentioned Elizabeth’s work with the Hawaii Medical Association — many people worked together to make this law a reality. I’d like to also acknowledge someone else from the Hawaii Medical Association, their executive director and my long-time dear friend, Mark Alexander.

Well, let’s start with Marschall. 

Marschall Smith: Dr. Ignacio.

Akina: OK, Marschall, I’ll follow your cue. Let’s start with Dr. Ignacio. And if you’d take no more than 10 minutes, just to kick it off, give us your perspective on what has happened, how to understand it, and we’re looking forward to what you have to share. Go ahead. 

Dr. Elizabeth Ann Ignacio: Thank you for that introduction and aloha and good early afternoon to all of you. I’m really pleased to participate in this session. I have no conflicts to disclose. Can you guys hear me OK? So I’m going to try to click through this here.

So again, I’m Elizabeth Ignacio, and I’m honored to serve the Hawaii Medical Association as the co-chair for public policy, as well as the new president-elect. 

I’ve been practicing for over 22 years. I live and work in Kahului, Maui, and all over the state. And I’m joined today with our knowledgeable IMLC director, Marschall Smith. 

So this is our AMA mission, and we do publish our legislative priorities every year. As you probably are aware, you know, there are several challenges that Hawaii healthcare has, and we focus — HMA focuses — on the physician shortage, telehealth issues, behavioral services, the issues that directly affect our patient ohana and also preventative screening and wellness issues.

Sorry, I’m trying to click and look.

So, many of you are probably familiar with these statistics, but I’ll just lay this out again in this part of our discussion that we have a worsening healthcare crisis in Hawaii, and there is some tremendous hardship and suffering for our citizens because of these shortages. 

You know, if you look at the statistics here, you can see that the physician shortages are worse on the neighbor islands: 40% for Maui, 37% to 40% in Hawaii County. This is from that report, legislative report, that comes out every year from [University of Hawaii John A. Burns School of Medicine]. The data is compiled in the fall — you know, this was probably the data from fall 2022 — and we know that this is worsening. We see — I see, personally — in all the different healthcare systems an attrition of physicians leaving every day, leaving their practices because they cannot survive.

They have such problems in the practice, and it’s an overwhelming amount of patients that we are dealing with, with not enough providers. 

This provider shortage is not specific to Hawaii; this is a national problem. And we’re not necessarily increasing, although we’re trying to, on the training end, bring in more physicians pipeline into all of our training programs for [Accreditation Council for Graduate Medical Education]. But the nation is suffering under a provider crisis for physicians, and we in Hawaii have to compete with the other states to deal with that shortage. 

So we do know also that through the pandemic, which kind of highlighted the problems of our healthcare system in Hawaii, that low-income individuals, families, Native Hawaiian and Pacific Islanders really experienced increased delays and worsening barriers to healthcare services, according to our 2022 Access to Care CDC-funded comprehensive survey. 

And the problems with healthcare disparities are multifactorial and complex, but it’s no doubt that it’s partly because of this erosion that we have of our Hawaii physician workforce. 

So I just wanted to sort of lay that out. I’m sure that all of us here in this room have experienced in one way or another those shortages for our family, our community, personally.

And enter SB674, which was the Interstate Medical Licensure Compact [that] went through the Legislature this last session. And we’re very excited about this bill that was signed into law by Gov. [Josh] Green this past month, and we’re beginning the onboarding process with the IMLC. 

There were, there was a lot of really good synergy working on this bill, as Dr. Akina discussed. A lot of the healthcare systems — [Hawaii Pacific Health], Queen’s [Health System] — as well as a lot of the health care provider organizations — not just physicians but our nursing associates, our psychologists, therapists, all [were] very supportive of the IMLC. 

Presently, I think that there is about 37 or 40 states involved with the licensure compact, some of those are new and onboarding.

Smith: Forty-one.

Ignacio: Oh, 41? So that’s great — and we are very excited to have this as part of the, as an important component of the solutions that we need to address the provider shortage, retention and recruitment of physicians to Hawaii.

And, I’ll lay out some of the questions that have been posed to me and to my colleagues regarding the compact that Marschall Smith will definitely address, including:

>> “Why do states differ in professional licensure requirements? How come we don’t have all the same?” 

>> And “What are the benefits and risks of the IMLC for quality and safety of healthcare in Hawaii?”

>> “Should providers apply to the IMLC so that they can provide telemedicine, telehealth elsewhere? Will that have an impact on our provider services here in our state?” 

Those are some of the, those are just a few questions that sometimes are batted around when people learn about IMLC. While we’re here, I will be happy to address how this IMLC is gonna integrate with our telehealth challenges.

As you know, telehealth, telemedicine has exploded through the pandemic, and it’s been a good thing that the permissions and the regulations were lifted through the pandemic in order to allow providers from other states to help us in Hawaii with our shortages. 

But as we are post pandemic, and some of those restrictions have come back into place, we need to make sure that we’re working together to help physicians provide services here, boots on the ground, as well as bring in other physicians and other systems who can help us in consultation services, help us with the spoke-and-wheel network of delivering services, especially to our underserved areas.

So, sort of just laying the groundwork for our discussion today. It’s not a conclusion, but a mahalo to you all for, for being here, for being engaged. 

We’re so grateful to Grassroot Institute — Dr. Akina, Joe Kent and your advocacy team — and we need to continue to work together to support each other for addressing some of these complex problems and challenges with healthcare, including the workforce and healthcare disparities in Hawaii. Thank you.

Akina: Thank you. Thank you for the opening statement. Before Dr. Smith gives his opening statement, Dr. Ignacio, let me ask you a couple of questions. 

When will the Interstate Medical Licensing Compact actually go into effect? Now, during the pandemic, the restriction against being able to use out-of-state licensed physicians was lifted by the emergency decree of the governor. But now, that’s been put back. So, when will this new law take effect, and what’s going to be happening until then? 

Ignacio: Well, you know, I wish we could just magically, you know, slam our fingers and bring this in immediately because we had these critical shortages, but it does take time to make sure. So …

Akina: Well, the governor does believe that there are some things that can be snapped instantly into an action. [Laughter] But let me let you continue.

Ignacio: But with the bill, I think it was 2025 …

Smith: January.

Ignacio: That was put in as the date that we would try to, to target. But we’re hopeful that within the next year, we would have, be able to be fully functional in this IMLC. We’ll see, and we’ll let Marshall handle that question also, in terms of the timeline. 

Akina: Now I know you’re concerned about the supply of nurses as well, and other medical personnel.

Ignacio: Yeah. 

Akina: How will the passage of the law that allows this compact for physicians affect other medical professionals? 

Ignacio: I’m really excited because I think that not only is IMLC going to help us in terms of boots on the ground physicians and bringing more providers here and integrating care with our mainland associates, but I think it can really help in terms of integrating care with our other healthcare professionals — our physical therapists, nurses and psychologists, for example — because you can have physicians not necessarily in one area, hopefully with integrated telehealth, be able to provide services in another area, whether, even if it’s remote.

Now, obviously telehealth has its own challenges in terms of infrastructure and bandwidth challenges that we have to address here in Hawaii, but IMLC can impact that positively. And further, I think having the IMLC here will help because we’re educating the state in terms of how compacts work, the way that they might benefit and sort of promote and move forward some of those other compacts.

They were introduced this past session for like nursing and psychologists and therapists. Some of them started conversations on how that can be helpful for our state. But maybe with our IMLC being in place, we’ll be able to show the benefits of that and help move forward those conversations for nursing, therapists, psychologists, etc.

Akina: Dr. Ignacio, you’ve mentioned telehealth several times, and so definitely the IMLC is going to expand our access to telehealth. How does that work under the new law? 

Ignacio: Well, so telehealth — telehealth is a complex, it’s a complex discussion in terms of the regulatory changes or the challenges that exist. 

Telehealth, as you guys know, maybe some of you have had telehealth visits with your providers and you know that they can be a benefit. We still need in-person providers to do physical exams and such, and sometimes those telehealth visits can take a little bit longer to find a diagnosis and start treatment because the provider is not in the room with you. 

So it can’t accomplish everything, but telehealth definitely can be integrated, and having the IMLC and having physicians in other healthcare systems that can serve in a consultative role and provide care for our citizens — especially because, you know, our communities, people are much more mobile across state lines — that they would be able to collaborate services. 

For example, if you were getting treated for cancer and your specialist was at MD Anderson or in California somewhere, they could help guide treatment. 

But, you know, telehealth has its own limitations for our underserved areas. And so, you know, if you don’t have a smartphone, if you don’t have access to smart devices, you’re not necessarily going to have access to all of the great benefits of a provider expansion that IMLC provides.

So we have to, in tandem with our IMLC changes, work with the state to improve the infrastructure and access of our underserved areas. It’s a big question, so I’m happy to elaborate more on telehealth in the discussion, but… 

Akina: Thank you. And I think, Dr. Ignacio, that some of our audience will have some questions during the Q&A period on telehealth, but thank you very much. 

Now, Marschall, I appreciate that you’ve come out here, and would you take the next 10 minutes and give us what we call your mana‘o — your thoughts — on what has taken place. You really are the expert on this issue at a national level. We’re privileged to you today. 

Smith: Thank you, and I appreciate the invitation from Grassroot to be here and talk to you about this.

I would like to start off by saying that, first of all, the Interstate Medical Licensure Compact is not — and is not bringing you — the solution to Hawaii’s physician shortage. You are going to be solving that problem. 

The compact, what it does is it’s bringing you a tool that your hospital association, your physicians associations, the citizens of Hawaii, Grassroot Institute, all of these organizations will figure out using this tool, ways in which you can expand and address that issue that’s important to you, and it’s important to other states. 

And I say this to every state that the compact comes into: We are not bringing you the solution, we are not providing you with the answer. We are giving you a tool, and a tool that is very effective. And I’ll give you examples as I start talking along of how other states and other organizations have used this tool to expand the care that’s provided. 

But again, I want to assure you that I’m not — I don’t have all the answers, I don’t have a backpack full of the solutions. You have those solutions. Your organizations here, your citizens here will do those solutions.

So let me go back up just a little bit and kind of go to a higher level and talk about what compacts are and what the IMLCC is. So the federal government, when the Constitution of the United States was developed, the framers knew that the federal government could only do those things that are — and they wrote it into the Constitution — they can only do those things that are specifically authorized to them. 

Healthcare is not one of the items authorized. And therefore, the framers, not knowing that we would be where we are now,  but in their knowledge and forethought in developing the Constitution, created in the Constitution clause — or, I’m sorry, the compact — a compact clause in the Constitution. I knew I could say that. 

And what that does is it allows states to enter into agreements with each other to solve issues that are, that involve two or more states. That’s what the compact is. It is a legal agreement that when Hawaii passed the bill, you entered into this agreement with the 40 other states that — let me back up — the 39 states, the territory of Guam and the District of Columbia have entered into. That’s why the bill was not — you couldn’t change the bill, you couldn’t alter it. It is a legal agreement between your state and all the other members of the compact. And it allows us to do certain things, and it creates an opportunity for us.

So the physician compact, specifically, it started as part of a discussion in 2013 when there were discussions about creating a national physician license and creating a national standard of practice for physicians. And the compact came about as a result of a meeting and a resolution by the Federation of State Medical Boards, um, House of Delegates.

And there was a discussion and what they did is that, that group came together and they said, “What criteria, if it’s met by an applicant and is verified by another state entity, would you, would you as a licensing board, accept and then issue a full and unrestricted license without doing your traditional or normal process?” And the IMLCC was the answer to that question. 

It’s very much, the analogy I use is: You all have experience with going to the airport. There are two ways. Everyone has to go through the X-ray machine. Everyone does. Whether you’re a pilot, or a TSA agent or anyone. You have to go through the X-ray machine.

Every physician has to follow the Medical Practice Act and get a license to do that in a state or territory. The way you get there is different. You can decide — and it’s your choice, and so is the IMLCC — you can take the traditional route — fill out the regular application, apply to all of the states that you want a license from. Use the traditional way to do that. 

Or you can do TSA Pre[Check], and you can take a step and get yourself so that you can move to the front of the line and go through it quicker, and that’s what the compact does. 

So our compact is available. Let me back up one more thing. 

So, primary source verified. So this is an assurance of the quality of the physician that is using the compact is this: The physician has to be licensed and practicing in another state, and that state has to verify from primary source — meaning they have a copy of the college transcript, they have a copy of the test scores, they have a copy, or they have the information that proves from primary source or the direct source, the information that the physician applicant is putting on their IMLCC application — so it’s not just the physician said he or she met these things. That is being verified by the board, primary sourced. 

So there is no such thing as a compact license. There is no such thing as a national license. Every licensel, and what the compact does is it provides an expedited way for physicians to obtain a full and unrestricted license issued by the board in, with the authority and the jurisdiction in that particular state. So physicians who use the compact will obtain a full and unrestricted license from the state of Hawaii just like if they would have gone through the regular process. It’s the same license. 

And that’s where when you get into issues and questions about telehealth or all of these other sorts of things. The type of license that they’re obtaining through the compact becomes irrelevant to that discussion, and the discussion can then be focused on how to best provide telehealth services and what to do; not necessarily that you, that the state of Hawaii, has to create a new license; because these licenses are full and unrestricted.

The compact itself — we are a governmental instrumentality. That’s a fancy name for meaning that when the bill passed here in Hawaii, the compact became a part of the Hawaii government. We’ve become a part of all of the governments that have joined the compact. That means we are part of your government, but we’re also not your government.

The example I give about what the compact or governmental instrumentality is: In Colorado, we have a lot of water things. Our water boards are governmental instrumentalities. They don’t have police authority, but they can regulate, and they can act, and they do have a government authority. They can pass rules, and they can enforce their requirements. 

So we became a legal organization in 2015, we started processing in 2017. We’ve been working in processing applications since that time. 

I became the executive director there in 2017. And I do appreciate calling me doctor, but I am not a doctor; I am a bureaucrat. [Laughter] So, and I appreciate being a bureaucrat, which is someone who understands complex things, finds good solutions and then helps people through the process.

So, let’s see — all of these slides will be made available, so I’m going to skip over a lot of this stuff. 

Hawaii will be represented in the compact. Your — the Hawaii Medical Board will appoint two commissioners. Those commissioners — Hawaii became eligible to appoint those commissioners as soon as the bill passed. So you are — I know the board is, I met with the board on Monday and Wednesday of this week to kick off the implementation process, and they are working on selecting those commissioners.

So onto the compact itself. So there are — the compact is now has 30, I’m sorry, 41 members. Hawaii was number 40, Missouri was number 41. 

We have legislation currently active in three states: Massachusetts, North Carolina and New York. We’re hoping — the North Carolina Legislature ends on the 31st; it passed the House, and we’re hoping that it gets through the Senate either today or Monday. New York and Massachusetts — we’re meeting with their legislative groups and interested parties and hoping to push that through. 

So, you’ll notice there are different terms up here, and Hawaii will — when they implement or go live — will participate in one of two ways, and this will be determined by the board and the authority that they are able to obtain and the permissions that they will receive.

So, a state of principal license, or an SPL, is the key to the compact process. The state of principal license is a license where a physician already holds a full and unrestricted license to practice medicine. That state of principal license already has all of that primary source documents because they’ve already given the physician a license. The state of principal license is key to what we do. So a state that can act as a state of principal license meets the nine criteria, and I’ll get to that in just a second — and I know I’m getting quick on my time. 

But the other part of it is, is all of our states that are active can issue licenses, which means a license can be issued even if they can’t be a state of principal license. These are two separate functions and two processes that happen. The primary reason we’re not able, some states are not able to do it — just to give you the behind the scenes dirty laundry — is they can’t get access to the federal FBI background check. 

And again, opening the door just a little bit, the state of Vermont has a medical board and a DO [doctor of osteopathy] board. They have the same authorizing authority, they have the same, they submitted the same application to the FBI, just changed the name of the board. The FBI granted authority to the DO board, but they denied authority to the MD board, and so Vermont has not yet been able to implement the compact. 

So as long as a physician is able to select a state of principal license, then they can use the compact process. Hawaii physicians can currently use the compact process, and I’ll explain to you how in my next slide. 

So, I’ve got two more slides I’m gonna talk through, and then I’ll kind of run through and highlight the rest of them. 

So the compact is set up in our, where there are two stages. 

The first stage is the physician has to select and be qualified to use a state of principal. That’s a state where they already hold a full and unrestricted license and they meet one of four criteria: They live in that state, 25% of their practice occurs in that state, their employer is located in that state or they use that state for their federal income tax purposes — that’s the military class that we use. 

Probably 70% of our physicians live in their state of principal. The other 25% [to] 30% are either 25% of their practice takes place there or their employer is located there. So a Hawaii physician can use the compact process if they are practicing in multiple states and at least 25% of their practice takes place in that state. So they may live in Hawaii, but they could still use the compact process. So it is open and available to physicians to be able to do that.

Then the nine criteria. So these are the nine things that the board said: “If these are verified from primary source and the physician meets these qualifications, we will issue a full and unrestricted license without doing our normal process” — meaning that most states from application submitted to license being issued following the traditional process takes six to nine months. Some states can do it as quickly as 60 days. Some can do it in 30 days. But most states, it’s a six- to nine-month process from application to license being received. 

The compact process — the first part takes on average 40 days, the second part is seven to 10 days. So once you have that letter of qualification, your state of principal has verified all of this, on average, you will get your license — all of the licenses that you’ve requested — in seven to 10 days. 

So we can get this process — again, and then once you have that letter of qualification, one of the things we know with our physicians is physicians that are going to be in multiple states always keep an active letter of qualification because they can just get their licenses quickly. So once you’ve got the letter of qualification, it’s good for a year, you can get licenses during that year. 

So you have to have graduated from a medical, an accredited medical school; no more than three attempts at the USMLE or the COMLEC; you have to have done your graduate medical education in the United States; you have to be board-certified; you can have no convictions or criminal activity; you cannot have a history of licensure actions on the MPDB report; you have to have a clean DEA [history]; the board that’s your state of principal cannot be having an active investigation; and then you have to submit and pass the FBI background check.

Those are the nine criteria. Physicians that meet those criteria, they can use the compact process. It’s a high bar standard. These standards are different and higher than most medical boards because it’s a, it’s a — and it’s also an on or off process, you either qualify or you don’t. There is no appeal. There is no request for adjustments or any of those sorts of things. You meet the criteria or you don’t. If you don’t meet the criteria, the physician has to follow the traditional process. 

So, and this is very small, and I will readily acknowledge that, but what I really want to point out is, I think there’s a — the compact when we first started, when I first started, we thought, “Oh my God, this is, this is a great thing, it’s, it’s, it’s pretty cool. We’re going to be, we’re going to be just ecstatic if we’re going to be processing 75 applications a month.” I mean that’s just, we just couldn’t dream of anything better than that.

Six months later, we were processing 200 or 300 hundred a month. But if you look at the June, from January 1st to June 30th, we’ve processed over 10,000 applications, letters of qualifications — those are physicians asking their state of principal license to give them a letter of qualification — and we have issued over 16,000 licenses to those physicians. 

And what we’re doing a data study, and I’ve talked with the people at the Grassroot [Institute], and we’re happy to share our data results and some of the things, but we’re getting ready to publish our, a data study where we’re looking at the new licenses issued in the United States.

Taking every state reports the number of new licenses they issue to the FSMB on a yearly basis. We know how many licenses were issued to those states through the compact process. We’ve heard anecdotally from our boards that they think that number is between 10% and 15%. And what we’re finding in the data — and again, it’s very preliminary, we’re not ready to publish it yet —but it appears that approximately a quarter of all the new licenses issued in the United States are using the compact process.

So it’s safe, it’s effective, it’s quick, physicians like it, boards like it, and it’s an economic boon to the state. Your state will see an increase in the number of licenses issued, which means an increase in their fees. 

And also the physician pays a fee to be a part of the compact; they pay $700. If a physician is paying or applying for two or more licenses, it’s economically beneficial for them to do that. It costs about $480 to apply for a license, to get all the documents and all of that sort of stuff two or more licenses, so two or more licenses — we’re cheaper. It’s one place. It’s all online. And Hawaii will get paid a portion to act as a state of principal license, so it’s an additional fee that they will receive to be able to do that. 

So let me quickly kind of jump to the end. So these are all the other healthcare related compacts. They all have executive directors. The key difference — and this is, this is an important difference between the way the IMLCC works for physicians and the other compacts work — we are an expedited licensure process. 

The physician using our process gets a license to practice. These other compacts are a privilege to practice, which means that they will be licensed in another state; there is a central repository of all of that information. So it’s not like a nurse from another state can come and practice in Hawaii and no one knows that. There is a repository of that information, and that information is available, and it’s controlled. 

And with that, let me jump to my information. And if you have questions, you can go to our webpage. There’s a lot of information there. This is my email address, I’m happy to — I’m going to be buried in emails when I get back — but I will respond to you over the next week, and thank you very much. 

Akina: Thank you, Marschall. Great job. Thank you very much. [Applause]

Smith: I still went long. 

Akina: Marschall, as you look at other states, after they have been approved for reciprocal licensure, what is the change we can anticipate in Hawaii of the availability of physicians? How many more physicians? What is the percentage or what is the number that you’ve calculated that we can expect based upon what you’ve seen elsewhere?

Smith: What we’ve seen is that, that most states typically — and this this is an average — but they will see, your board will receive and process between 10% and 15% more applications. And the significant part of that is it’s not just like a big bubble and then it drops off. What all of our boards have experienced is this: They see an increase in the number of applications for physician licensure, and it’s a sustained number, and it actually starts going up.

We have five boards that have actually increased the number of physicians being licensed in their state [so much] that they’ve reduced the licensure fees for all physicians because they’re, again, getting, bringing in more funds and revenue than they thought they would. So, all of our states have experienced, at a minimum, a 10% increase in the number of new physicians being licensed in the state.

Akina: Now, with the expansion of the opportunity into the market itself … 

Smith: Yes. 

Akina: … there are some who have claimed this is going to be a negative impact upon local doctors because there will be an increase in competition. What is it that you actually see happen, and in what ways will our local doctors actually benefit from the expansion of the market?

Smith: Yeah, and that’s an experience that is a concern that’s expressed a lot; it is not, has not been proven valid. 

I think it would be a legitimate concern if there were more physicians in Hawaii than you had opportunities. Yes, if every physician was — you know, if you had more physicians than you have opportunities, that would be a problem. It’s not been a problem. 

Where this is really going to — these are solutions that other states have done, and I think you in Hawaii will start figuring these out too — your hospitals, your hospital association, your medical society are all going to get into these.

But the example that was given a little bit earlier by Dr. Ignacio about MD Anderson: When Texas joined the compact, MD Anderson came up with this idea and how to use the compact. They cut their credentialing costs in half. The hospital itself cut their credentialing costs in half because they’re using the compact to get their physicians licensed.

They also changed the way in which they — they’re a specialty center. The Mayo Clinic has adopted this, the Cleveland Clinic has adopted this, John Hopkins is in the process of adopting this process. But what they did is they changed the way that they provided care to the patient. And I think Hawaii, you’re perfectly suited to be able to do this too.

The traditional way was if you had cancer and you were going to MD Anderson, you traveled to Houston for your preoperative care. You may have gone two or three times for your appointments. You received your treatment at MD Anderson, and then you came home, and then you went back for your post-operative care.

What MD Anderson did is they, using the compact, said, “Where is the patient located? We will get the physician licensed in that state.” The patient, if it’s appropriate — again, this is, it’s a tool — if it’s appropriate, the patient goes to their local doctor’s office and has a consultative visit in the place where they’re comfortable and safe and know the physician, they’re in a good spot. They do their pre- and post-operative care locally with their local physician, and they’re able to do that because the physician that their doctor is, the patient’s doctor is consulting with is licensed to practice in that state. And so it’s a big thing that will happen, and I think you will find in Hawaii, that will help.

The other thing — if you don’t mind — the other thing that we’ve seen happen, and this is especially in rural and underserved areas, we know that 45% of the doctors that get licenses through the compact obtain those licenses so that they can provide care in rural and underserved areas. So they’re — the physicians that are getting these licenses — are aware of that need too.

The example that I’m going to give you is, it happened in the upper part of Wisconsin. And if you know your geography and the map, the — it’s two to four, two to three hours to Madison and to Milwaukee, which are the primary physician centers, from the northern part of Wisconsin. It’s 30 minutes to 45 minutes to [pause] Minneapolis. Why can’t I suddenly remember the name? 

So what those hospitals and those clinics did there is they created opportunities where physicians from Minnesota could get licensed in Wisconsin. Those hospitals have expanded their hours, they’ve expanded their services, and they’ve done it through one of two ways, or using both ways.

One is they actually have the physicians close enough that they can come into the clinic once or twice a week, but they also use telemedicine. And then that physician gets licensed in the state, they can practice in that state. They now then can enter into collaborative agreements with advanced practice nurses, with PAs, The physician can supervise nurses and provide care. They’ve created the contracts with radiologists so that they can provide the radiology care. So the requirements of the hospital or the clinic can be met because they’re doing it with a licensed physician who’s licensed in their state.

Akina: Thank you very much. We’d love to have any questions you in the audience have. In order to help us out and include your questions in our broadcast, would you come up to this microphone that Melissa is standing by? Introduce yourself and ask your question. 

Thank you, and again, Marshall and Elizabeth, appreciate all the input you’ve given us so far.

I’ll appreciate it too if your questions can be brief and our answers brief as well. So we’d love any of you to participate. Please introduce yourself, Rob. 

Rob Burns: My name is Rob Burns and I’m, I defeated the then-governor running mate for that position. Anyway, in 2008, we had the best system in America, supposedly, and I was wondering what amount of doctors we had during that year before we changed over to wanting to use your own doctor if you could find one. 

Akina: Thank you, Rob. Marschall, do you want to take the stand and give us some kind of estimate? 

Smith: I don’t know. I, uh, 2008 … Yeah, I don’t know. 

Ignacio: Are you referring to a change in licensure? Or a change in coverage? 

Burns: I just find it hard to find a doctor nowadays. And, supposedly we had the best in the U.S., and then we went along with, get along, and then all of a sudden we had one of the worst. I was wondering if we knew how many doctors we had at that time versus what we have now.  

Smith: Let me look it up. 

Akina: Thank you, Rob. Please, next.

Suzy Kehne: My name is Suzy Kehne. 

Akina: Could you step a little closer and reintroduce yourself? 

Kehne: My name is Suzy Kehne. I’m from the islands. I have two questions: 

One is, what’s up with California and Florida? They’re gray on your map. Because California should be a primary feeder for us. 

And two, what’s happening in the world of psychiatric services? And the psychiatric social workers who have been doing telemedicine work during the pandemic and where are we in terms of being able to use primary sources with [inaudible]?

Akina: Thank you, Suzy. I’ll let you take that.

Smith: So I will answer the question about Florida and California. The states, as I mentioned, the compact itself, we can’t lobby, we can’t introduce legislation. We do not have that authority. It has to be organic to the state and getting that introduced. That’s where Grassroot was fantastic here in Florida or, Florida — Hawaii. Florida and California, all of the gray states, they’re — they have decided not to participate in the compact. 

California, I will say, we have had several requests and made quite a few presentations to them. The very, very blunt answer is they just, they’re just too big, they really don’t care. 

Florida has had several studies that have proven that it makes a lot of sense to the state of Florida, that it will actually be an economic boon to the state to be a part of the compact. But then they tend — their politics tends to get them involved in other things, and providing licensure for physicians falls off the list. 

But they’ve done several studies, and it’s proven that it actually makes a lot of sense. A lot of Florida physicians use Georgia, Alabama to get into the compact. So we do have a lot of physicians located in Florida who are using the compact, but that’s that answer. 

Ignacio: And to answer your question about the behavioral health, we continue to struggle with having enough providers for, for physician providers, counseling, psychology providers, so it’s still quite a challenge. 

It was worsened through the pandemic, and it has not recovered, so there is expansion of telehealth services. They’ve been at the forefront of a lot of telehealth regulatory changes across the country, but it’s still a challenge here in Hawaii that we have to work on. And hopefully the IMLC and bringing more providers will be helpful in that regard.

Akina: Thank you. Yes. 

Kate Zhou: [inaudible]

Akina: Welcome professor. 

Zhou: Thank you. I was thinking about, when you talk about the doctor shortage in the United States. So this kind of compact is good, but in the long run, since Hawaii is the Asian Pacific recruit, this kind of a compact, including Asia Pacific, because we, especially Hawaii, you know, we have Chinese, Korean, Japanese, Filipinos, the shortage really can be overcome.

So I’m thinking about it, is that how the leadership of, you know, medical association, we were kind of an Asian Pacific company. And so, telehealth, or whatever, and UH medical school can help to kind of train medical ethics. They can get a master’s degree; even though they have their doctorate degree, they can get a master’s degree.

So online, also, you know, on campus. What do you think of that kind of possibility? Maybe with you, maybe, a situation can be done. 

Ignacio: That’s a great question, and it is really important that we bring in physicians that have cultural competence, that understand our cultural and ethnic diversity here in Hawaii.

And I think these are — I theorize myself, as well as my other colleagues, how IMLC and other measures may help in terms of bringing more physicians who have that cultural competency and understanding. We want to actively promote programs where we educate our physicians about specific cultures and their backgrounds or language challenges and such so that we can address barriers that way.

We want to bring in physicians that have those cultural backgrounds because we found that in other states — for example, California or Texas, which also have quite diverse populations — that when the physicians are a part of that culture, and they reflect that culture, that the outcomes of their patients are actually better, so we do want to bring those in. 

Now, how do we do that? There’s pipeline initiatives. There’s ways that we want to increase training. So we bring physicians, we bring trainees here who can understand our community and the challenges specific to our communities, and those physicians, those trainees that are receive their training here are more likely to stay, so we want to expand our training programs. 

And also by bringing more physicians into our community — which we’re in crisis right now — we can support the healthcare, the healthcare system in general. We can have more mentorship, mentoring opportunities for our physicians to learn if they have more physicians in the community. So there’s different ways that we hope to address that. And like you, I feel that that should remain a real priority for our, for our state. 

Akina: Thank you.

Ignacio: Absolutely.

Akina: And thank you for your question, Dr. Zhou. Next, please.

Judy Akin: Hi, I’m Judy. I’m actually a patient. I’m a rare disease patient, and living here in Hawaii with multiple rare diseases is extremely challenging.

I was wondering what you guys think, how this will impact clinical trials. Because I have applied for clinical trials left and right and I’m constantly denied, and I’m sure it has a lot to do with location. So I’m really excited to see if you think this will have a positive impact on clinical trial participation.

Ignacio: I’m not sure, Marshall, if you have any specific data or …

Smith: No, I don’t, but we are actually, the — and I’m sorry, I can’t remember the name — but the physicians that handle rare and complex diseases, and I do apologize. I don’t, I don’t know. 

Akin: I work closely with the National Organization of Rare Diseases.

Smith: Right. Yes. And we work with them, and they endorse the compact and the compact process for exactly the same reason that you’re pointing out — is that by getting their physicians licensed in more states, they can then get in a broader pool.

And, but, you know, if you’re not licensed there, having a patient there — you can’t have a patient there. So it will have a positive impact. They believe it will have a positive impact, and they’ve partnered with us in helping to get the compact through.

Ignacio: Right. And also, I’ll just add that up until this point in Hawaii, we had some reciprocity-slash-exception rules that would allow for collaborative consultation for rare disease issues for other health care systems to integrate with UH and other hospitals in our state. 

But they’re not efficient, they don’t necessarily address liability issues for the providers, and if you have, with the licensure expansion that would happen with the IMLC, I theorize, as do my colleagues, that you’ll be able to have better integration for these collaborative teams — tumor boards, specific pathologic disease boards that can address this in multiple areas and draw from that collective knowledge — so I am very hopeful that this will help. 

Akin: Me too.

Akina: Thank you for that question. Any other questions? We have time for one or two more. Yes, please. Go ahead.

Jesse Miller: I get all this nice treatment. Nobody else got that, right? Well, thank you for the presentation. My name is Jesse Miller. I’m the founder of Pacific Housing Association. So my question, let’s say if I’m a new physician, trained up, and I’m in — I don’t know, I’m from Washington state originally — and I’m trying to be recruited to move over to Hawaii here, what are the things that come up in terms of objections? 

Why is it that they say, “Oh, I decided I don’t want to go to Hawaii, I’m going to go to Idaho or something”? Something else in that sense. And do you have any statistics for that too on surveys or anything like that as well? 

Smith: Go ahead. 

Ignacio: So I think the question is, like, what are some, what are some issues that come up when we’re trying to recruit physicians here to Hawaii because why wouldn’t they want to be in Hawaii? It’s wonderful here, our sense of community and aloha that is so real. Why wouldn’t everyone want to practice here? 

And when you talk to the young physician trainees that are out there, a lot of them are graduating with significant debt. It costs a lot to train a physician. They’re young adults and they are trying to start their families. They’re trying to — they’d like to have a home, and as we know that the housing challenges here, it’s very expensive to live here. 

So, it is hard to sell the Hawaii aloha when people have this extremely high debt that they’re finishing their training with. They look for job opportunities where they are going to be able to handle that and have a lifestyle that’s livable. They’re not looking for a luxurious lifestyle, but something that’s livable where they can, you know, manage their families. 

So, that, I think, is the No. 1 thing that is daunting for a lot of our young trainees: the debt that they have and the cost of living here. 

Now, it doesn’t mean that it doesn’t happen. We still bring physicians — if we can bring trainees here and they experience the community, a lot of them want to stay. So one of the big barriers is just having them experience the life here in the community here. 

And then, another barrier to bringing physicians here can be, “Well, if you’re in practice here, and what is it like for the reimbursements here?” And unfortunately, reimbursements are pretty low here for physicians, and that is part of the factor. And how are you going to sustain your practice? What support do I have to keep my practice open? 

And some healthcare systems are very helpful in bringing new physicians into the community and helping them sustain their practice. But that’s a very daunting challenge: starting in practice or joining a practice and not knowing how sustainable it is. 

Akina: Thank you very much, and thank you for the question. 

Everyone, would you join me in showing our mahalo and deepest appreciation for Dr. Elizabeth Ignacio and Marschall Smith. Great job today. Thank you so much..

Smith: Thank you. Thank you. [Applause]

Akina: It’s been wonderful to hear their expertise, and I hope you’re inspired. And let me close on this thought: What we have celebrated today is deeply profound. It’s not just the passing of another law. 

As you know, the Grassroot Institute, along with many other people, stands for three principles: individual liberty, economic freedom and limited accountable government. And where those principles are propagated, we see a society that thrives. 

Today, we’ve talked about how the lofty principle of economic freedom. In other words: reducing the interferences in the marketplace, reducing the over-regulation of government. 

We’ve talked about how economic freedom has had a victory here in Hawaii this last legislative term. A victory by allowing the free flow — or the freer flow — of medical servicing and the increasing of access to physicians. 

That’s a practical win for people who are in pain and suffering and who need medical care. But it’s also a philosophical win for those who want to celebrate the fact that economic freedom can help people in our society to thrive.

And that is worth celebrating, and that’s worth spreading to other professions as well. And that’s why we’re deeply grateful to our partners who have helped bring that about and thank all of you for supporting this kind of transformation of society.

Let’s work together. E hana kākou. [Applause] Thank you, I’m really glad you’re here. 

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