Hawaii’s Healthcare Shortage; Hawaii Island Residents Concerned

From Grassroot Institute

“Hawaii has done a great job at getting everybody health insurance, but having health insurance does not equate to having access to healthcare.”

That was one of the observations expressed by Lisa Rantz, executive director of the Hilo Medical Center Foundation, during the latest episode of “Hawaii Together,” hosted by Grassroot Institute of Hawaii President Keli’i Akina, on the ThinkTech Hawaii online network.

Rantz said the state’s healthcare shortage has been acute on the neighbor islands for years, and, “I think as the shortage increases, we’re starting to see more of the impact on Oahu.”

Hawaii overall is short about 1,000 doctors, she said, leaving the state with “the most acute primary care shortage in the nation — and we also have a nursing shortage.”

Rantz said legislators have told her, “Hey, if we don’t have primary care providers, we can have nurse practitioners or physician assistants come in and provide primary care and preventative care.”

The bottom line, she said, “is we have a shortage of all of those things, and it’s very hard to fill those positions, especially specialty positions, which we found during COVID.”

Rantz said the shortages are the result of a “perfect storm” that includes Hawaii’s high cost of living; young doctors graduating from medical schools with “an exorbitant amount of debt”; Medicare reimbursements that are the lowest in the nation; and Hawaii’s pyramiding general excise tax, which takes a significant bite out of doctors’ low revenue margins.

In addition, Hawaii’s certificate-of-need laws “seem like another layer of bureaucracy that may not be in the best interest of our community members getting access to the high-quality care close to home that they deserve.”

Rantz said there is a lot of information about Hawaii’s healthcare shortages, but, “We can’t just keep reporting. We need to take action, and the time for action is now. We’ve seen it during the pandemic, and we need to move this forward. There’s just no way around it.”

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TRANSCRIPT: 12-6-21 Lisa Rantz with Keliʻi Akina on “Hawaii Together”

Keliʻi Akina: Aloha, everyone, ane welcome to “Hawaii Together” on the ThinkTech Hawaii broadcast network. I’m Keliʻi Akina, your host and president of the Grassroot Institute of Hawaii.

Well, Hawaii is no paradise if you are in critical need of medical care. That was the title of my article, or at least close to it, “Hawaii Is No Paradise If You Need Medical Care,” in the weekend’s edition of The Wall Street Journal on December 3rd.

There I mentioned that even before the pandemic, Hawaii needed 800 additional doctors and about 2,200 non-physician personnel. That was just to meet the needs at that time.

Our high taxes and high regulations have driven medical workers from the state and have limited our healthcare policy, and so have some regulatory practices that we’re going to talk a little bit about today.

However, I want to introduce to you now somebody who knows this work because she’s actively involved in advocating for healthcare for the residents of Hawaii and, in particular, Hawaii Island. Today we’ve got again on our program Lisa Rantz, the executive director of the Hilo Medical Center Foundation.

According to Lisa, residents of Hawaii Island are voicing their concerns now about the shortage in healthcare. Maybe you’ve known of people from the neighbor islands and the Big Island, in particular, who had to wait months in order to see a specialist and then have had to fly to Oahu to do so, or sometimes even less availability to them. Lisa is currently conducting a very important survey of residents about access to healthcare on the Hawaii Island.

I’m just very pleased today that we can dive a little deeper into this issue with Lisa.

Welcome to the program, Lisa. You’ve been executive director over there at Hilo Medical Center Foundation since 2014, I believe. I want to welcome you back. Glad to have you back on the program today.

Lisa Rantz: Thank you so much, Keliʻi. Always a pleasure to be on your show and spread the word about what we need to do to make things better.

Akina: You’re doing very important work.

As you and I were chatting just before the program, I have to confess that five to 10 years ago, very rarely did I hear people talk about the shortage of medical need in Hawaii. I knew of it somewhat. Statistically, I knew of certain issues and concerns, but living on the island of Oahu, where we seem to have all the medical care that we need, we weren’t aware of how acutely the problem existed for our neighbor island friends.

Now that I’m thinking about it, the many, many stories that I’ve heard through the years of neighbor islanders having to wait and wait and wait to get medical care, it seems as though the problem is getting worse. Would you say that there has been a lack of awareness of this problem, and now we’re starting to learn more about it?

Rantz: Yes. I think that there’s been efforts like the annual Hawaii Physician Workforce Assessment that’s been banging this drum for the last 11 years and really trying to highlight the shortages that are taking place on the neighbor islands, but out of sight, out of mind, right?

With your population based on Oahu and not having shortages on Oahu, you don’t know what that’s like; you don’t know what it feels like. You don’t want to know what it’s like to have to receive cancer care but be told that you can’t get it on island, and you have to travel either to Oahu or the mainland to get care and then not feel very good and then have to travel back home. That takes you away from your support base, your family, your comfort of your own home.

I think as we’ve seen more neighbor island folks getting care on Oahu, as our shortages increase across the neighbor islands, we’re starting to feel that on Oahu. When you call your doctor and they’re like, “Oh, you can’t get in for two weeks,” or “We can’t see you for three weeks because we have appointments from neighbor island community members,” then all of a sudden it hits home. I think as the shortage increases, we’re starting to see more of the impact on Oahu.

Akina: Lisa, I would agree with you that on Oahu, we’re becoming more aware of the plight of our neighbor island neighbors, with respect to healthcare availability.

We’re also starting to realize now that this is not just a rural or neighbor island problem; it is a statewide shortage of medical personnel and facilities that we have. In fact, in my opening comments, I mentioned that we had a clear-cut shortage even before the pandemic and going into it. During the pandemic, we’ve become all the more aware of how critical our shortage is here in Hawaii.

Before we continue, I just want to take a moment and ask you to share a little bit about your background in terms of being what you call yourself today and what I observe you to be, a healthcare advocate and educator.

Rantz: Absolutely. I was actually a teacher before I joined Hilo Medical Center Foundation. My first task was to build out the community arm of the foundation, which involved support for the Hawaii Island Family Medicine Residency Program, the only residency program located outside of Oahu.

It became very clear that we had to work on the infrastructure to make it possible to hire physicians in the community, with getting a health profession shortage area designation, or a HPSA, which allows for loan repayment, which if you want younger providers to take over existing practices of aging providers, you need that loan repayment because education is very expensive now.

Then that also provided a 10% bonus payment to our physicians in practice for all of the direct-billed Medicare services, which is intended to help increase that Medicare rate, which we have the lowest in the nation here in Hawaii.

Hawaii has done a great job at getting everybody health insurance, but having health insurance does not equate to having access to healthcare.

Akina: I appreciate all of the advocacy you are doing in that regard.

You mentioned to me that you had seen my article in Wall Street Journal this weekend, the one entitled, “Hawaii Is No Paradise If You Need Medical Care.” Any thoughts on that? Did we dovetail on some of the observations you’ve made over the last few years?

Rantz: Absolutely. You reported on the nursing study that showed that Hawaii County has the third-largest shortage in our nation, followed by Maui County at No. 5 and Kauai at No. 13. If you look at No. 1 and No. 2, they’re in areas that are very close to metropolis areas or populated areas where you can drive. In Hawaii, we’re rural and remote, and we cannot drive; we have to fly to get healthcare.

Really talking with our congressional delegation, as well as our state legislators, on working on efforts where we can actually move the needle. It’s one thing to report that we have these shortages, and they go up. Even from your article, it’s gone up to 1,008 from 820 is what our current shortage is for the state. That’s pretty significant. [chuckles]

Akina: The fact that we have a medical capacity shortage is something that figured prominently in the rationale by our government leaders for many of the lockdowns and some of the restrictions that we experienced and are continuing to experience in the pandemic. In fact, there has been a specter described [as] overrunning our medical facilities.

In terms as clearly as possible for us to understand, what is the medical shortage here in Hawaii, and how severe is it?

Rantz: As I just stated, just for physicians, we’re short over 1,000 providers. We have the most acute primary care shortage in the nation, and we also have a nursing shortage. When you couple that, we have legislators that have told us, “Hey, if we don’t have primary care providers, we can have nurse practitioners or physician assistants come in and provide primary care and preventative care.”

The bottom line is we have a shortage of all of those things, and it’s very hard to fill those positions, especially specialty positions, which we found during COVID.

You don’t have respiratory therapists; we don’t have the critical infrastructure that we need in our healthcare system. We have the least amount of beds in our hospital system per capita in the nation.

That’s why we had to lock down because there just wasn’t the capacity to deal with the surge, because we’re already, on a regular day-to-day basis, running a very high census, especially since so many folks paused their care during COVID, and now they’re going in because they’re sicker, and they need more acute attention than they did ahead of the pandemic. It’s just a difficult situation.

Akina: We’ve talked about what the problem is, but why does it exist? How did this happen here in the state of Hawaii, and what are the factors that have contributed to the shortage?

Rantz: We like to refer to that as the perfect storm. [chuckles]

We have a high cost of living. Our students, when they go into medical careers, come out with an exorbitant amount of debt, and to look at the housing costs as well, so that goes into the cost of living.

Electricity is higher, food prices are higher, and then the reimbursements are the lowest in the nation. You make less money and have higher bills; it’s difficult to recruit young folks here.

Then you’ve got parents that have lived here, maybe families, for generations, and every generation wants the next generation to do better than the one before. I think we’re facing the first generation who’s going to do worse than their parents did.

I think parents recognize that, and they’re actually telling their kids to stay on the mainland, get their loans paid off, buy a nice, big house, raise your kids, and then as the parents get older, then you can move back home, and you can help take care of me.

What we’re actually seeing is that these folks are moving, and they want to be closer to their grandkids. We’re losing population in the state of Hawaii, and healthcare is one of the largest reasons why.

Akina: When you talk about the exodus of people out from the state of Hawaii, you mentioned many of the factors such as the cost of living, which includes, of course, the cost of housing and so forth. Not only that, the difficulty of carrying the kinds of educational loans that are needed to go into the medical profession.

What do you think the solution would be to this? Let’s start at a more ground-level point of view in terms of future practitioners of the medical arts here in Hawaii, future doctors, future nurses and so forth. Is there anything we can be doing now to help encourage them and empower them to stay in the state of Hawaii …

Rantz: Absolutely.

Akina: … or return to the state of Hawaii?

Rantz: Yes, absolutely. I think community members are exceedingly grateful for healthcare.

When we recruited a cardiologist two years ago, he said that he was thanked more in the first two weeks of being at Hilo Medical Center than he was in 10 years of practice on the mainland. I think that gratitude goes a long way, but we can only work for pleases and thank yous for so long.

Many of our providers, because the Medicare rate is so low, lose money on Medicare patients, so they need that commercial payer mix. One way to fix that is working through the congressional delegation to try and get an increase in the Medicare rates, something on par with Alaska.

If we are successful in doing that, what I’ve been told is then our commercial rates will go up because the commercial rates are based off of that Medicare rate. That’s bad for business, and that’s bad for individuals, adding to the cost of living.

Another option is something that the state can control, and that would be relief from the general excise tax. The general excise tax is a gross receipts tax, and the hospitals don’t pay it, nonprofits don’t pay it, which means our federally qualified health centers, providing care to some of the most vulnerable, are not burdened with that.

Our community physicians that are at the front lines of caring for our Medicare patients, for our Med-QUEST patients, TRICARE, our veterans — right? —  they’re not allowed, or they’re not able, they can’t afford to take on those patients because they have to pay that tax. They can’t pass that tax onto those populations.

Akina: Lisa, that may be a little bit difficult for the average person to understand because, first of all, the GET that you’re talking about, general excise tax, doesn’t sound like it’s all that much. It’s a tack-on 4% to 5% in most of our eyes, something we do when we pay groceries. I’ve met a lot of people who find it very difficult to believe that this can be a make-or-break issue for medical doctors.

As I’ve listened to doctors — those that are not employed by big corporations who have their own practices and have to maintain their own businesses — the GET, along with the rate of reimbursement for Medicare, combine in a very big way. Apparently, they have a very small margin they make, so the GET and Medicare rate take a huge bite out of that. Is that how that works?

Rantz: It is, and so being a gross receipts tax, doesn’t equate to 4.5%; it’s more like 15% to 20% of a practice cost.

When you’re looking at a margin, a typical practice, 70% overhead, 30% is what they make on the margin, but they have to pay at least half of that in the general excise tax, from what we’ve read on the research and looking at the analysis. It just makes it very difficult to be a viable practice, with a higher cost of living.

We actually just lost three providers here in East Hawaii on Hawaii Island that are closing up their doors and moving to the mainland, because they can’t make the numbers work. They just can’t do it.

Akina: That’s fascinating and also tragic because I think very few people have any idea as to how hard it is for somebody trying to make a living in the medical profession to do so. What you’ve provided to us is information that’s very insightful.

When we come back from a quick break, I’d like to ask you to tell us a little bit about the survey that you are conducting that will give us some insights into the problems that our people are facing.

I’m going to come back in just a moment with Lisa Rantz, executive director of the Hilo Medical Center Foundation, and you’ll be with us on ThinkTech Hawaii’s “Hawaii Together.” Don’t go away.

[INTERMISSION]

Akina: Welcome back to “Hawaii Together” on the ThinkTech Hawaii broadcast network. I’m here with Lisa Rantz. We’re discussing a very important issue, the shortage of healthcare in Hawaii.

She’s done a marvelous job of advocating for that, not only on Hawaii Island, but statewide. She’s the executive director of the Hilo Medical Center Foundation.

Lisa, you’ve got a project going on now, which is a survey to determine access to healthcare in Hawaii, what people’s perceptions of that is and what the reality is about that. It’ll be very important.

I understand it began on the Big Island, but it’s actually turned into a statewide project. Would you tell us a bit about that?

Rantz: Yes, I would be happy to.

It’s a comprehensive community health needs assessment. It was always intended to be a statewide project.

We wanted to start it on Hawaii Island because that’s where the most acute shortages are. We have a 53% shortage of providers, or 287, according to the Hawaii Physician Workforce Assessment.

Plus, I’m president for Hawaii State Rural Health Association, and our office is on Hawaii Island. It just made sense to start here since the nursing shortage also indicated that Hawaii County is No. 3 in the nation.

What this is is we actually just wrapped up the survey. We did a community survey asking community members if they can get care when they need it. If they can’t get care, what care are they not able to get? Do they have to fly to Oahu, or do they have to go to the mainland to get that care?

Then HMSA is also sharing their data with us as far as what’s being flown off-island by procedure code, so we’ll be able to start triangulating this data to show exactly what our shortages are and what we need to recruit for.

The other thing, which is unprecedented in these assessments, is we’ve pulled providers together, physicians and nurses, et cetera, and asked them, what do they need to continue to be able to provide care in our rural communities? What’s working well? What supports could maybe the insurance companies or policymakers and community members provide to them so that we can continue to have access to care close to home? There was also a provider survey that went along with that.

What we’re seeing in the initial results out of Hawaii Island is patients are having a hard time getting care. The providers are saying that some patients, especially new patients, are at least a month out from getting any sort of appointment. If it’s something acute, they refer them to the emergency room to get that service.

The other piece that we’re seeing is the cost of care. Community members are postponing care because they get the bill that has the tax that’s being passed on from the providers, and they’re unsure as far as the copays and what that tax is.

It prevents our most vulnerable populations from going and getting that scan that can diagnose their cancer early. It’s very unfortunate.

Akina: The survey is sponsored by what organization, and who’s paying for it to get done?

Rantz: This came out of monies from the Biden administration. This was a CDC, a Center for Disease Control, grant that went to the Department of Health. We worked very closely with the Office of Primary Care and Rural Health.

We’re doing all of the islands, starting in Hawaii island. Then in the first quarter of 2022, we’ll be launching simultaneously on the other islands, with the focus groups and the surveys.

We are working very closely with Hawaii State Rural Health Association, the Pacific Basin Telehealth Resource Center, the County of Hawaii; we’ll loop in the other counties in the first quarter, and Community First, which was started by Barry Taniguchi in 2015 to address some of these issues that we’ve been talking about today.

We contracted with Community First as the lead organization to help push this forward. Obviously, Hilo Medical Center Foundation is very Hawaii Island-centric, and we really couldn’t take the lead on that.

Community First is a wonderful organization doing great work. They have the Our Kuleana project that was started just ahead of the pandemic to get folks to take responsibility, wear masks, do the handwashing, et cetera. This is an important partnership as we move across the state.

Akina: Obviously, one of the aims of the study will be to generate a greater awareness of the need for increasing healthcare resources in Hawaii. Hopefully, that will result in more funding in that regard.

Rantz: Exactly. I’m sorry to interrupt you.

This is just the first step. This assessment is just phase one, and then we’re going to be able to report it out and then bring it back to the key stakeholders so that we can create that action plan.

Where are the low-hanging fruits? Are there policy changes that can be made that can start moving this needle forward?

We can’t just keep reporting. We need to take action, and the time for action is now. We’ve seen it during the pandemic, and we need to move this forward. There’s just no way around it.

We actually have a commitment of some small funding from some donors. The Department of Health has a little bit of money to start helping move this forward. This is going to hopefully help our state legislators as they go into this session to know what to do with the monies that they’ve received from the federal government.

Akina: That’s good.

Lisa, we get questions from time to time from viewers. The following question just came in, and it indicates that those who may suffer from a shortage of healthcare services and resources are not just our local residents.

Here’s the question: What do you think will happen to Hawaii tourism if the Legislature does not address the provider shortage crisis in the immediate future? Interesting question.

Rantz: Yes. I think that if people knew how dangerous it was to be here, if you suffered trauma hiking, there’s no trauma helicopters on Hawaii Island.

We have people that come to visit, and they think that they’re going to have a great time, but we see people drown. We have visitors that suffer cardiac arrests.

I think the big push to say that Hawaii is the safest place to travel is a misnomer. We don’t have the services to support the tourism industry.

We need to be looking at other industries to step up to be able to fill in that gap. Perhaps instead of putting the burden of the general excise tax on our private-practice folks, we look at reverting that back to 1931, the reason why they started the sales tax, [which was that ] they didn’t have a big enough base.

We have a tourism base that comes in. We should be able to do something with that. I’m not an expert in that. [chuckles]

Akina: Your thinking is in the right direction, however. At the Grassroot Institute, we have been advocating for removing the GET from medical and food as well. That’s the direction most states are heading. We’ve got some catching up to do, to say the least.

Very briefly, there are some regulations in our state that also impact the availability of healthcare. One of them is a certificate-of-need requirement. Any quick thoughts on that, and if you could define that for the viewers?

Rantz: Yes. I don’t deal directly with the certificate of need or the SHPDA [State Health Planning and Development Agency] organizations.

We’re actually working a little bit on the Hawaii County organization that does the certificate of needs to help with some videos to help our community members navigate the healthcare system. That was my first story into the certificate of need, but then listening to their process of how they decide whether we have the economies of scale or the population to add services was interesting to me.

I don’t know enough about it to really make a large comment on the certificate-of-need process, but what I’ve read is, it’s a little bit antiquated, and the federal government doesn’t fund it.

This is a little bit from your article, and, yes, it just seems like another layer of bureaucracy that may not be in the best interest of our community members getting access to the high-quality care close to home that they deserve.

Akina: Lisa, I want to thank you so much for being on the program with us today. The things you’ve shared are very important. We need to be talking about them.

I really appreciate the work that you’re doing and looking forward to the results of the survey.

Rantz: Absolutely. We’re looking forward to sharing the results.

Akina: Thank you very much.

Lisa Rantz has been my guest today. She is the executive director of the Hilo Medical Center Foundation. We thank her so much for her insights.

I’m Keliʻi Akina with “Hawaii Together” on the ThinkTech Hawaii broadcast network. We’ll see you again in a couple of weeks. Aloha.