Doctors leaving Hawaii fed up with red tape

Low reimbursements and high malpractice insurance costs are driving out specialists

Dr. Terry Smith says he is calling it quits after 16 years of caring for patients on Oahu and the Big Island because of "impossibly low" reimbursements for what he is expected to do.

One of four spinal surgeons in Hawaii, he figures he is making about half the income he did 10 years ago while working harder with increased liability and "a lot of bureaucratic mumbo jumbo," he said.

"If someone figured what we get paid an hour, considering we're on call 24/7, it's about $30 an hour, about what a carpenter makes, for the risks involved," he said recently. "It is no longer worth it to me. ... I'm burned out."

Dr. Morris Mitsunaga, one of two orthopedic surgeons on call at the Queen's Medical Center's trauma center, also is fed up. "It's pretty much a crisis statewide," he said. "It would take just one or two more people dropping out, and we won't have a safety net taking care of people."

Government reimbursements far below costs of caring for Medicare, Medicaid and QUEST patients coupled with medical malpractice costs are driving specialists out of Hawaii, the doctors say.

"It's going to create a huge void," said Dr. Linda Rasmussen, Windward orthopedic surgeon and Hawaii Medical Association president-elect.

Mitsunaga said Queen's has "got its fingers in the dam" trying to maintain the state's only trauma system.

A shortage of orthopedic surgeons on the neighbor islands and problems transporting patients to Honolulu result in delayed care, he said. "So there are a lot of high-risk things people (doctors) don't want to take on or do because of risk for liability."

Physicians who treat uninsured patients run the risk of getting sued, he said.

Some obstetrician/gynecologists are no longer delivering babies because of liability, Rasmussen said.

Richard Meiers, Healthcare Association of Hawaii president and chief executive officer, said Hawaii Pacific Health's recent move to reorganize its hospital operations because of high costs and low reimbursements reflects turmoil at all hospitals.

"Hawaii's health care system, as we have known it, is rapidly disintegrating," he said.

Meiers said health care executives have been telling legislators for years that federal and state reimbursements must be increased "to ensure that government pays a fair share of treatment costs."

The state's medical malpractice insurance law also must be reformed to reduce high costs, "which have been driving physicians from practicing in certain specialties and even practicing in Hawaii," Meiers said.

Costs of providing care in Hawaii are among the highest in the nation, Meiers said, yet federal payments to Hawaii health care providers amount to only 37 cents a dollar spent. And Medicare rates are expected to drop an additional 25 percent during the next five years, he said.

Frank Camozzi, manager of the Medicare Policy and Provider Services Branch, Centers for Medicare and Medicaid Services in San Francisco, said in a telephone interview that the centers set the rates based on a complicated formula from Congress.

Medicare rates in Hawaii are about 4.4 percent above the national average, Camozzi said. "Nationally, Hawaii is about in the middle of the country."

He said many states have rates lower than Hawaii, but he "can't argue" with the fact that Hawaii has higher living costs than most.

Meiers said, "We're seeing more and more physicians who are refusing to treat Medicare and Medicaid patients, and now we're seeing it with workers' compensation (cases) because reimbursements were set by the Legislature 11 years ago."

Smith said medical malpractice reform is important, but his biggest issue is poor reimbursements. "Ultimately, it will be critical. The people leaving are not being replaced. And it will end up costing a lot more money to get new physicians than to retain physicians they have here," he said.

Smith noted that he is called routinely in the middle of the night by hospitals and patients. "Basically, I have to be available 24 hours, seven days a week. I live here, but if you saw how white I am, you would never believe I live in Hawaii."

The 54-year-old surgeon came here in 1984 for his medical residency, became a spine specialist and has been in private practice since 1990. He flies at his own expense to Waimea, Hilo and Kona on the Big Island to see patients -- twice a month at each site -- and also sees patients at Castle Medical Center.

"The state is paying an enormous amount of money now with the lack of orthopedic surgeons on the neighbor islands," Smith said. "They are air-evacuating people now with broken fingers."

Emergency room physicians at neighbor island hospitals do not want the liability of treating such cases, he said. "So everybody with any kind of problem now is being sent to Queen's."

He said the three other spine surgeons are busy but will treat life-threatening cases. However, people with back or arm pain probably will have to be treated nonsurgically, and "outcomes may not be as good," he said. Neurosurgeons also do some spine work but generally not the full gamut of spine care, he said.

Smith said he has been hired by a company for temporary-location assignments of two weeks to three months starting June 30. The company will pay for his flights, car, housing, malpractice insurance and a set salary.

But he will continue living here. "I can make more money with less hours by working on the mainland and flying to and from here."

Smith's loss "is huge," Rasmussen said. "He flies to the neighbor islands, all on his nickel. He doesn't get reimbursed any more, then HMSA hits him again with decreases in reimbursement."

"Things are happening that make me lose sleep at night," she continued. "When people go to ER and sit there 10 hours and can't get care, and Queen's is backed up, and especially on the neighbor islands, it's horrible."

Patients are waiting four to five days in Hilo to have a fracture fixed because there is only one orthopedic surgeon taking calls there, she said, noting that delayed treatment increases risks of blood clots and complications.

Further distressing doctors, "reimbursements are totally controlled" while they have no control over expenses, Rasmussen said. "Because we have one (primary) insurance company, HMSA, they can dictate to us what they will pay. ... They're always lowering reimbursements."

Cliff Cisco, HMSA senior vice president, said adjustments are made for different specialties each year, and there have been decreases for some surgical procedures in the past.

But there has not been any decrease recently, he said. "Overall, reimbursement has increased, and it is higher than Medicare."

But Rasmussen said Hawaii physicians "are at the end of their rope. We continue to work harder for less reimbursement, with increasing costs, and you get to the point that it just doesn't make sense to stay here."