Hawaii's All Out Crisis in Medical Care – Doctor Shortage Only Worsening

By John Bellatti M.D.


Rumors of my retirement are much exaggerated. I am an orthopedic surgeon in my 20th year of practice here in Kona. I read the Jan. 17 article in a Big Island newspaper on the M.D. shortage with great interest, including “don’t fracture a bone in Kona because there’s not an orthopedic surgeon.” Later that day, during my second surgery, fixing a broken hip, it occurred to me that perhaps the statement was correct. Perhaps I really did retire, and I’m just having one of those “work dreams.” So I pinched myself. No, I didn’t wake up from this bad dream.

We have an all-out crisis in medical care — a sinking ship. “No new patients” policies are commonplace at existing physician’s offices and more practicing physicians are contemplating jumping into the lifeboats. This problem is not going to turn around in the next six months. But what we do matters.

Realistically, if you are contemplating bringing a family member closer or moving to Kona, reconsider: There will not be adequate medical care available. Most of the readers of WHT do not want to join the emigration to the mainland. There is much hand wringing. Some ask the governor, HMSA, or the Legislature to “do something.”

The success of the U.S. has not come from its governments, nor its large corporations, but from its people, acting in their own interests, and with community spirit. The people of West Hawaii can take this problem into their own hands. Some may not agree with what I am about to say. Great, investigate, cogitate, and communicate. Twenty-five years ago, hospitals, clinics, and medical schools fell all over themselves, tearing down “hospital,” “medical center,” “medical doctor” signs. The term “health care” replaced “medical care.” When you have a heart attack or fracture a bone, you need medical care which is shrinking in Kona.

In order to convince physicians to stay and more physicians to move here, the reason for departures must be faced. The top reason every physician who has left or limited practice has done so, as personally told to me, is “HMSA.” Reimbursement rates are low for the services that physicians supply. Hassle factor is high for the services and prescriptions that physician recommends. When the extremely well paid HMSA executive responds to this letter, just ask yourself — do I believe him or my own eyes?

We need an independent investigation and audit of HMSA just like the one done for the Bishop Estate 10 years ago. For 2005, HMSA had a cash flow of $1.7 billion and a reserve fund of $700 million (see http://www.hmsa.com/about/annualreport/2005/fin_stmt.asp ).

This is not subject to any oversight. Remember the old Bishop Estate trustees? Before the Bronster investigation, the papers carried statements that there was nothing to find, that this was a waste of money and time. After the investigation, the discussion of time turned from “waste of time” to jail time.

HMSA continually points to the fact that most physicians “participate” as a sign that most physicians are happy enough with their fee schedule. You’d participate too if someone had a full-nelson on your income. There is a check box on the insurance claim form where the patient can request that the insurance payment be sent to the physician instead of the patient. HMSA simply ignores this. “Non-participation,” for those physicians who tried it (I did once) means too commonly that patients use the check to pay for rent and buy gas, beer and cigarettes and other necessities, before considering paying for the medical services already received. HMSA uses human nature to enforce its protection racket on physicians.

Physicians who might be considering relocating to Hawaii hear of this, and realize they will not be able to set their own fee schedule. It’s HMSA way or bankruptcy — or don’t move here. One urologist did move here without realizing this reality. He left after three months.

This strong-arm practice would be ended very easily if Insurance Commissioner Jeffrey Schmidt could simply issue a regulation that all companies providing medical insurance must honor a request to send the reimbursement directly to the physician. But when it comes to things like this, HMSA says it is not an insurance company. It will take a Legislative statute to bring about change. This is harder because it means the populace (you) must rain down demands on the Legislature to fix. That’s the only way it will happen. Whether or not you are an HMSA member, this problem is seriously affecting you.

A third absolute requirement to attract physicians is to enact medical tort reform — a dollar limit on medical malpractice claims for non-economic damages. This would end the medical malpractice lottery where a very few attorneys can seek huge awards, of which they get one-third (plus expenses). Only a few attorneys in our state participate in the lottery. The rest are in the same boat with us when we or our families need medical care that is not available here.

There is a growing number of states where tort reform has been enacted. Malpractice insurance becomes less expensive; doctors move in. Presumably some of the affected attorneys moved out to greener pastures, like Hawaii. Again, only a concerted effort by the large number of citizens who consider that they might need a doctor for more than flu shots will force our attorney-dominated Legislature to act.

This issue pits the medical plaintiff’s attorneys (small number) against the entire population of the state. In the past five years have you benefited from the current non-reformed system? Did you get to deposit the big check? Or, have you or a family member been negatively affected by the current system — long wait in the ER, trouble finding a doctor to be “your doctor,” deliver a baby, or fix a fracture?

Tort reform does not impede anyone’s ability to sue a doctor for malpractice; it just means your attorney may give you better advice on what is realistic to expect. The alternative is no doctor – no malpractice. In an ethical legislature, tort reform would already have come to a vote at least once. Sylvia Luke, malpractice attorney and chairperson of the Judiciary Committee, not only failed to recuse herself from decisions on a tort reform bill, she absolutely blocked discussion of this bill in committee. Don’t let them dodge the issue again. Rain down e-mails, faxes, letters and phone calls. We need medical tort reform now. It will benefit most of us.

I have outlined two key elements of the medical doctor shortage in Kona and in the state: HMSA’s death-grip on the reimbursement levels for physicians and continuation of the medical malpractice lottery for a few attorneys.

I have pointed out three key elements to attack and win.

* 1. HMSA must have a Bishop Estate-like investigation and public audit.

* 2. HMSA (and other payers) must be made to accept the request of their members to make payments directly to physicians.

* 3. The Legislature must pass a meaningful medical tort reform bill.

Any reader may feel ineffectual in writing a letter. If 1,000 Kona residents write one letter a week, and send it out to 10 people (legislators, senators, governor, HMSA execs, state bar association, insurance commissioner), then modify it and do it again next week, 50 weeks times 10 recipients times 1,000 citizens is 500,000 calls for action. Residents from the other islands would join in because you copy your e-mail to your friends, who do the same. Try 10,000 letter writers with 10 copies sent. One hundred thousand letters a week. This is attainable.

We don’t need another emergency summit with politicians, bands, and grinds, to hear more blah-blah-blah. We need the personal, earnest, broad-based, consistent, tenacious efforts of our many concerned citizens to pummel our elected officials into putting our interests first.

The Legislature and governor must step up to the plate and do just these three things to represent their constituencies. We do not elect leaders, we are the leaders. Let’s remind our representatives. The next election is a long way off. This problem can’t wait.

Please, make this problem your problem. The time to act is now.

Dr. John Bellatti is an orthopedic surgeon in Kona, Hawaii.
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