Shortage on Big Isle seen at crisis stage

One physician likens the island's situation to an overtaxed electrical grid

STORY SUMMARY »

Of all the neighbor isles, the Big Island is experiencing the greatest population increase, making the doctor shortage there most acute.

Perhaps most critical is the shortage of orthopedic surgeons, because car accident victims can be left in the lurch when no one is on call -- especially on weekends -- and must be flown to Honolulu.

Dr. John Bellatti, a Kona-based orthopedic surgeon, compares the remaining doctors' situation to an electrical grid, which when overburdened must shut down to avoid further damage.

He says health care on the Big Island is in a crisis, with high overhead and low reimbursements likely to cause more private physicians to pack up their bags and leave.

Some stick it out because of local family ties. But even for many of them, job prospects on the mainland are beginning to look better and better.

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Dr. John Bellatti, an orthopedic surgeon based in Kona for 20 years is just plain tired.

The Doctor is Out series » Yesterday: Oahu's main trauma center is swamped. » Today: The shortage is most severe on the Big Island. » Tomorrow: For isle medical students, the future too often lies elsewhere.

Last week, he had five surgeries scheduled in one day, when a call came in from Waimea at 8 p.m. for a patient with an open-fracture ankle.

Though it runs counter to his instincts as a physician, Bellatti said he had to turn it down.

If he had accepted it, he would have been operating until midnight, and with only four hours of sleep, he would have woken up the next day to other operations for his regular patients.

It was a hard lesson to learn, after being on-call part of the year for 13 years.

In the meantime, the shortage of orthopedic surgeons has grown more severe on the Big Island, as what used to be six has dwindled down to three full-timers and two part-timers.

For any major trauma, such as a highway car collision, chances are the victims will have broken bones and will need to be flown to Oahu if it's a weekend.

"I have personally realized that I cannot run the 'gun lap' day after day, month after month, year after year," said Bellatti. "I have a certain sustainable capacity to work and no more. I am frequently turning down patients who really deserve to be seen, but I cannot simply discharge other patients who are already in my practice."

Bellatti compared the doctor shortage to a failing electrical grid on a hot summer day -- with an overloaded system that shuts down to avoid damage.

In Kona, said Bellatti, there is a brown-out.

"I think the all-out shutdown of private medical doctors is on the horizon," he said. "There will still be a very few maintaining their existing practices, and large parts of the population will have no doctor."

At the same time, more retirees are moving to the Big Island to live out their golden years, and families are moving their grandparents here to care for them. Between 2000 and 2006, Hawaii County's population jumped 15.1 percent, from 148,677 to 171,191, according to the Hawaii Data Book.

Bellatti is advising his patients not to relocate their parents to Kona for retirement because of the health care situation.

"The choices are very limited, and some don't like the few choices available." he said.

Bellatti, who did his medical residency in Honolulu, said he was part of an idealistic group of physicians who hoped to build a medical community in a beautiful place. After 13 years of practice, however, he began to see it decay.

New opportunities on the mainland come across Bellatti's desk every so often, and he considers them because he's realized Kona may not be the ideal place to retire for him, either.

Although the debate about medical tort reform continues, doctors say it is one way to help make Hawaii a more attractive place to set up a practice.

Some new physicians have come and gone in Hilo. The success of federal programs which offer to repay student loans in exchange for working in underserved areas remains to be seen.

A cap on non-economic damages might stabilize the market by lowering malpractice premiums, according to Kailua orthopedic surgeon Linda Rasmussen. She said there are currently large fluctuations due to high awards in a small market.

Paula Arcena, director of the Hawaii Medical Association, said California's tort reform has been held up as a model for Hawaii. There, she said, the money from lawsuits is shifted toward the plaintiffs rather than the attorneys that represent them.

"California came to a crisis where the hospital emergency rooms were shutting down," said Arcena. "That's what's been happening in states that are passing tort reform -- the problem grows until it's out of control. We don't want to get to that point."

In addition, Rasmussen says health insurer Hawaii Medical Services Association should make direct payments to the physician rather than the patient. That way, non-participating physicians could get their payments, without having to go after it through a collection agency.

Dr. Doug Hiller, a Waimea orthopedic surgeon since 1996 and head doctor for the Olympic Triathlon, said another factor is reimbursement rates, which he called significantly lower than on the mainland -- even though the cost of living here is as high as many mainland metropolitan cities.

Hiller, 57, was sorry to close second office in Kona, but said that the overhead became too high while the reimbursement was too low.

"It just didn't pay the rent," he said.

Cliff Cisco, senior vice president of HMSA, there is a constant pressure between the physician's desire for more income and the employer's desire to keep employee benefit costs down, so health insurers are caught in the middle.

"It's true that we are lower than some areas on the mainland," said Cisco. "There's no question we are lower than some metropolitan areas (such as San Francisco and New York). HMSA is in the middle."

Hiller said he toys with the idea of relocating to the mainland, where he could make twice as much, with fewer hours. But having grown up in Hawaii, he remains committed to staying.

Unfortunately, as more doctors leave, those who remain are left with even more patients.

Dr. Peter Matsuura, 49, is holding the fort in Hilo as the only orthopedic surgeon available on-call.

Matsuura, who grew up in Hilo, sees between 500 to 600 patients a year, and operates almost every night.

There have been efforts to recruit new doctors, without much luck. The reimbursements in Hawaii mean smaller margins, according to Matsuura.

At the same time, he said the doctor-patient relationship is not what it used to be, say in the '50s and '60s. Today, the emerging trend is toward an assembly-line type of medicine.

"Society has made it mercenary," he said. "Now most of us see patients as commodities or liabilities."

Yet the patients are what keeps him going. He gets up night after night when his beeper goes off, believing that he will be saving somebody's life.