Physicians' financial burdens threaten isle health care
TWO RECENT articles in Hawaii newspapers pointed out a relationship between inadequate reimbursement and reduced access to physicians ("Senior healthcare in Hawaii: Is it enough?" West Hawaii Today, May 19, and "Doctors leaving Hawaii fed up with red tape: Low reimbursements and high malpractice insurance costs are driving out specialists," Star-Bulletin, May 16).
We believe that as patient advocates, physicians must speak out and address issues that threaten access to care. Inadequate reimbursement affects the health of everyone in our state, not just seniors. Physician services also are threatened by skyrocketing mal- practice costs. We would like to offer the following additional comments:
» Medicare doesn't pay doctors fairly to account for the high cost of living in Hawaii. Medicare usually adjusts what it pays doctors based on different costs of living. A major problem with Medicare's Hawaii fee schedule is that it does not account for our extraordinarily high cost of living. For example, Hawaii's cost of living is comparable to urban areas such as Boston or San Francisco, but Medicare will pay a doctor's office in Hawaii 10 percent less than one in Boston, and 18 percent less than one in San Francisco. That is, while our cost of living is ranked among the highest in the nation, Medicare reimbursement is only near the 50th percentile.
» Hawaii Medical Service Association, Hawaii's dominant private insurer, pays doctors unfairly. Despite claims by HMSA representatives in the Star-Bulletin article, HMSA actually pays doctors less than Medicare. For example, in Hawaii, for a new patient with several chronic illnesses, HMSA PPO plans pay doctors 84 percent of what Medicare pays. Its HMO plans pay even 15 percent less than the PPO fees.
Even more striking is that although families pay the same premiums to HMSA that they would to other mainland Blue Cross companies, HMSA's payments to doctors are much lower. For example, families in Hawaii pay the same premiums as families in California do for Blue Cross of California. Despite this, HMSA pays doctors at a rate as much as 60 percent lower than Blue Cross of California.
» Hawaii's general excise tax unfairly penalizes doctors. Hawaii is the only state that imposes taxes on all health-care services: Doctors' offices here are required to pay the 4 percent GET on all revenue for professional services. Other Hawaii businesses that also are required to pay the GET can pass this cost on to customers by charging an additional 4 percent for their services. However, Medicare (and sometimes HMSA) prohibits doctors from collecting that tax from patients. This amounts to a 4 percent tax on doctors who agree to care for Medicare patients, and drives the low Medicare payments even lower.
The same is true for Medicaid and Quest reimbursement -- but in this case the state says that the tax is "included" in the reimbursement. This logic implies that the state taxes itself on its own Medicaid payments, a rather absurd concept that simply disguises the fact that doctors are really paying the 4 percent GET out of their own pockets.
» Escalating medical malpractice costs are driving doctors from practice in Hawaii. Obstetrical and trauma care are most threatened, as these physicians are the hardest-hit by malpractice premiums, but all doctors are affected. A recent bill supported by Governor Lingle to reform malpractice was passed by our state Senate and two House committees, but was stymied by Rep. Sylvia Luke, who refused to allow the bill to be heard in the House Judiciary Committee. Of note, Luke is a personal injury attorney, who commented that this bill would not help retain doctors in rural areas of Hawaii: "I don't think this bill is necessarily what they are trying to achieve."
We're not sure where Luke gets this information. As practicing doctors, we strongly feel that rising malpractice costs are a huge problem here and factor into many Hawaii doctors' decisions either to leave the state or retire early. In addition, malpractice reform laws have been passed in other states recently where poor access to care is a problem.
» Because of the above problems, Hawaii can't retain doctors or attract new ones. Local hospitals have noticed this problem and are boosting physician recruitment efforts. But because of relatively low payments by insurers compared to the mainland and the malpractice crisis, hospitals can't get doctors to move here unless they provide relocation assistance and start-up funds. This strategy is only partly successful: the low reimbursement rates, the high cost of living, the malpractice costs, the day-to-day hassles of running a small business in Hawaii, the onerous on-call responsibilities, and the very attractive and lucrative job offers from the mainland cause many doctors to leave.
We see doctors come, and we watch them go. We are in a state of medical crisis, not only on our island but in the entire state of Hawaii. There are too few doctors, patients wait far too long to see them, especially for specialty care, and certain care is unavailable. Reduced access to doctors will equal worse health-care outcomes for the people of Hawaii: poorly controlled diabetes and hypertension leading to stroke and heart attack, and cancers detected too late for a cure are two examples.
It is time for our elected officials to help fight for stability.
TO ALL concerned families and residents of Hawaii, please ask our leaders to: lobby Medicare for fair payments to doctors that accurately reflect our high cost of living, as they do on the mainland; eliminate the GET on health-care services; hold HMSA accountable -- if it collects premiums at mainland rates, it should pay doctors mainland rates; and push for malpractice reform to retain the doctors we have and help attract new ones, as other states already have done.
We deeply appreciate the rewards of living in these beautiful islands and caring for all the wonderful people here. In this spirit, we grow more and more worried about the disparities in care between Hawaii and the mainland. Ignoring this fact won't make the problems go away: If we do nothing, the problems will only grow worse.
This column was signed by 45 medical professionals. They are:
Ronald Ah Loy, M.D.
Lora Aller, M.D.
Linda Anegawa, M.D.
N. John Anegawa, M.D., Ph.D.
Clif Arrington, M.D.
David Arthurs, D.O.
John Bellatti, M.D.
Barry Blum, M.D.
Dinah Bukowski, M.D.
Mary Jane Castro, M.D.
Beth Catanzaro, M.D.
Donna Ching, M.D.
Pradeepta Chowdhury, M.D.
Thu N. Chowdhury, M.D.
Stephen H. Denzer, M.D.
Alan C. deSilva, M.D.
Frank Ferren, M.D.
Buddy Festerling, M.D.
W. Douglas Hiller, M.D.
Michelle R. Huber, M.D., M.P.H.
Craig Kadooka, M.D.
Ghulam Kashef, M.D.
Young Rhan Kim, M.D.
Edward J. Kirshen, M.D.
Peter Locatelli, M.D.
Peter Matsuura, M.D.
Jade P. McGaff, M.D.
Pamela McKenna, M.D.
Dale McSherry, D.C.
Aaron H. Morita, M.D.
William Park, M.D.
Robert Patterson, M.D.
Heajung Ruesing, M.D.
Richard Miller, M.D., Ph.D.
Niall Scully, M.D.
Neal Shikuma, M.D.
Robert R. Sloan, M.D.
Sylvia Sonnenschein, D.O.
John Stover, M.D., Ph.D.
Ronaldo Toledo, M.D.
Rebecca Townsend, M.D.
Sharon Vitousek, M.D.
Allan Wang, M.D.
Armand J. Wohl, M.D.
Howard Wong, M.D.
