Scarcity of specialists creating local crisis

[Miulang]

Re: Scarcity of specialists creating local crisis

Does medicaid/medicare reimburse differently in hawaii than on the mainland?

For Medicare, which is a federal program, sort of (payment is made by DRG's--diagnostically related groups---which means payment is capitated depending on what region your facility is located and for senior citizens, who usually get treated for a multitude of ailments when they see their provider, reimbursement is only paid out for one of the therapeutic treatments per admission/visit, not all.) If you spend more than the government says it will pay you or it costs more for your facility to provide the services because you have older facilities or are located away from a large city, etc, you lose. If you're more efficient and can get your patient out the door sooner, you win. That's why there is this "revolving door" going on with elderly patients...they get discharged before they are totally recovered because the hospital doesn't want to lose money. On Maui, because there aren't enough long term nursing beds, Medicare patients end up taking hospital beds that could be used by younger, more critically ill patients.

Medicaid is a combination of fed and state, mostly state.

Miulang

[brianca]

Re: Scarcity of specialists creating local crisis

So the amount paid for a certain treatment varies based on location? Where does hawaii stack up in the scale?

[timkona]

Re: Scarcity of specialists creating local crisis

Going to a doctor is a choice. For that reason they should be immune to lawsuits. In the event of malpractice, they should lose their right to do any more doctoring.

It's a SUE happy society we live in.

[Miulang]

Re: Scarcity of specialists creating local crisis

So the amount paid for a certain treatment varies based on location? Where does hawaii stack up in the scale?

Yes, it depends on the severity of the primary disease being treated and where the provider is located. They have this really arcane formula they use to determine regional reimbursement rates. When I was in grad school studying this stuff, the health administration researchers discovered that people on the East Coast, where the health infrastructure tended to be older and the general population was older as well, it cost more to treat a patient. Out West, where facilities in general tended to be newer and people younger and healthier, it cost less. So when DRG's were first implemented, the providers in the West were actually making money while the ones on the East Coast were losing money.

However, with the aging of the population (the Boomers) and with increased migration of these people away from the East Coast and the Rust Belt for warmer climes, I think the whole formula is getting skewed. I believe the Centers for Medicare and Medicaid (a department under the US Dept. of Health and Human Services) readjusts reimbursement rates periodically to reflect inflation and other factors.

Here's a rather pithy academic explanation of the differences between Medicare and Medicaid.

Miulang

[joshuatree]

Re: Scarcity of specialists creating local crisis

I wonder if building out a state of the art hospital ship or even procuring an existing one from the military would help offset the medical staff crisis on the outer islands? Clearly the outer islands don't have the population sizes to profitably sustain a full fledge medical facility locally. So with a hospital ship, you have your full staff plus all the equipment. The ship cruises around the islands minus Oahu (no need there I presume ) to serve all the communities without adequate facilities. Short term patients can visit the ship the few days it's in port. Those requiring longer term treatment stay on board. These are big ships, like cruise liners, maybe the island hopping would be therapeutic to recovering patients too. Medical staff do tours of duty. As for emergency patients when the ship's not in town, these ships are equipped with helicopter pads for a fly in, just like those you see at Queen's. Just my random thought to the issue.

[helen]

Re: Scarcity of specialists creating local crisis

Nice idea but such a ship would need to stop off at Oahu for refueling, taking on supplies, staff rotation.

Also I don't think it helps the residents of Kona much since they don't have harbor to handle deep draft ships.

Another thing to keep in mind that for long term care not only do you have to deal with the patient, but with the patient's family or friends who want to visit the patient during the long term care. Kind of hard to do if the patient is being treated on a ship that is off-shore.

[Miulang]

Re: Scarcity of specialists creating local crisis

I wonder if building out a state of the art hospital ship or even procuring an existing one from the military would help offset the medical staff crisis on the outer islands? Clearly the outer islands don't have the population sizes to profitably sustain a full fledge medical facility locally. So with a hospital ship, you have your full staff plus all the equipment. The ship cruises around the islands minus Oahu (no need there I presume ) to serve all the communities without adequate facilities. Short term patients can visit the ship the few days it's in port. Those requiring longer term treatment stay on board. These are big ships, like cruise liners, maybe the island hopping would be therapeutic to recovering patients too. Medical staff do tours of duty. As for emergency patients when the ship's not in town, these ships are equipped with helicopter pads for a fly in, just like those you see at Queen's. Just my random thought to the issue.

This, actually, is a very good idea in theory. Project Hope has a ship like this that sails off to foreign countries on medical missions. There might be some logistical complications at Neighbor Island ports because most of the navigable ports are seriously overcrowded, but I would think that a medical mission to serve local residents is more important than tourism.

Miulang

[joshuatree]

Re: Scarcity of specialists creating local crisis

Nice idea but such a ship would need to stop off at Oahu for refueling, taking on supplies, staff rotation.

Also I don't think it helps the residents of Kona much since they don't have harbor to handle deep draft ships.

Another thing to keep in mind that for long term care not only do you have to deal with the patient, but with the patient's family or friends who want to visit the patient during the long term care. Kind of hard to do if the patient is being treated on a ship that is off-shore.

I think refueling, taking on supplies, disposal of waste, and staff rotation could be done in hours at Oahu. But if the ship is out there every 30 days and only needs to stop at Oahu for one day, I think it's well worth it.

The ship need not literally dock at the port. The military hospital ships are designed for that.

As for family, there are two ways you can approach this. The ship returns back to the same location every few days so family could merely visit then and keep in touch via phone on the days the ship is elsewhere. Or, maybe a "hotel" can be fitted into the ship for families willing to pay for accommodations? Not saying a floating hospital is perfect but just thought it would be a creative solution to an acute problem.

This, actually, is a very good idea in theory. Project Hope has a ship like this that sails off to foreign countries on medical missions. There might be some logistical complications at Neighbor Island ports because most of the navigable ports are seriously overcrowded, but I would think that a medical mission to serve local residents is more important than tourism.

Miulang

Same as mentioned before, perhaps the ship can merely lay anchor off shore? Check out the USNS Mercy.

http://en.wikipedia.org/wiki/USNS_Mercy_%28T-AH-19%29

* Patient Capacity:
o Intensive care wards: 80 beds
o Recovery wards: 20 beds
o Intermediate care wards: 280 beds
o Light care wards: 120 beds
o Limited care wards: 500 beds
o Total Patient Capacity: 1000 beds
o Operating Rooms: 12

* Departments and Facilities:
o Casualty reception
o Radiological services
o Main laboratory plus satellite lab
o Central sterile receiving
o Medical supply/pharmacy
o Physical therapy and burn care
o Dental services
o Optometry/lens lab
o Morgue
o Laundry
o Oxygen producing plants (two)

[WindwardOahuRN]

Re: Scarcity of specialists creating local crisis

What is happening on the neighbor islands is very much like what many of the rural areas of the mainland experience. Many remote areas of the mainland have extremely limited access to healthcare, necessitating hours of travel to visit specialists or receive emergency care. Airlifts are frequent happenings in these places, as they are in Hawaii.

Is it inconvenient, perhaps life-threatening at times? Yes, it certainly is. But it is a fact of life in remote areas and I believe it always will be.

I don't believe that you are going to have MD specialists, who can make extremely nice salaries in other areas of the country, coming to Hawaii in droves. Let's be honest here---the insurance payments are not going to suddenly increase, the operative costs of medical practice are not going to decrease. Any possible one-shot monetary incentive will be quickly eaten up by the COL of Hawaii. Real estate costs, education costs, and other things will factor in to making other areas of the country look much more attractive to a doc who is thinking of the future of himself and his family.

The military is not going to provide an enormously expensive floating hospital when all the islands have permanent facilities. If a patient has to go to Oahu for treatment the cost of a commercial flight is extremely inexpensive compared with the cost of maintaining a medical facility which is basically just for convenience. No neighbor island airport is further than ninety minutes away from Honolulu. The cost of a Project Hope type ship is simply not justifiable.

Practical solutions? Telemedicine---already being done in many remote areas of the country and just starting in Hawaii.

http://starbulletin.com/2006/10/01/news/story10.html

If a neighbor island patient has to go to Honolulu for specialized treatment, perhaps a tax credit for expenses or a government fund to help defer those expenses?

And about all those retirees heading to Paradise from doctor-soaked areas of the mainland? I have heard plenty of shell-shocked admissions of ignorance from patients and families when the kim chee hits the fan, health-wise. They are appalled that there are so few medical options available on Kauai, for example. Totally flabbergasted that they had to be strapped into an Air Ambulance plane for a bumpy ride to Honolulu for something that would have been treatable in a local hospital back on the mainland.

Oh well. Perhaps a bit more research and a few reality checks, pre-Paradise, would have been helpful.

It's nice to dream about state-of-the-art medical care for all the islands but the practicalities of it make the prospect most unlikely.

[joshuatree]

Re: Scarcity of specialists creating local crisis

I never said the military provide a medical ship for the state, only suggested perhaps procur one from them, considering the military constantly decommissions older vessels. As to who procurs one, I dunno, whoever usually builds a land based hospital? HMO? State?

Telemedicine is definitely one area that should be pushed but I think it still has a long way to go when you need the full amenities. I would guess a bean counter is needed to crunch the numbers. You can't compare a medical ship to just one physical hospital but rather to all the supposed number of hospitals you need to staff and build out on the neighbor islands. Then we can see if a med ship is viable or not.

[Miulang]

Re: Scarcity of specialists creating local crisis

And about all those retirees heading to Paradise from doctor-soaked areas of the mainland? I have heard plenty of shell-shocked admissions of ignorance from patients and families when the kim chee hits the fan, health-wise. They are appalled that there are so few medical options available in Kauai, for example. Totally flabbergasted that they had to be strapped into an Air Ambulance plane for a bumpy ride to Honolulu for something that would have been treatable in a local hospital back on the mainland.

It's nice to dream about state-of-the-art medical care for all the islands but the practicalities of it make the prospect most unlikely.

You hit it right on the kinipopo, WORN! People spend more time deciding between different models of cars to buy than they do about what kind of medical care they need or will be able to find in an emergency. And that's a crying shame. Maybe if more Mainland retirees realized before they got to Hawai'i that if they had a stroke or heart attack on a Neighbor Island that they might not be able to get treated in a timely fashion or if they have a chronic disease that requires specialized care which means a trip to see the specialist off-island, they might want to reconsider and move to someplace like Phoenix.

And telemedicine would be a wonderful thing for the rural hospitals in Hawai'i to have. Then they wouldn't have to worry about the high cost of supporting specialists. But medical technology costs money, and about the only way Hawai'i will have these high tech solutions is 1) if private hospital development companies are allowed to invest and build state of the art facilities or 2) the Federal government mandates that all hospitals, regardless of location, have to have this technology available. If they could do that with HIPAA, which required all hospitals to make pretty extensive investments in CIS software and computers, then they certainly could mandate that hospitals upgrade to provide this service.

Next step after that is to set up Regional Health Information Organizations (RHIOs) so that participating facilities and providers have the ability to share pertinent clinical information about a patient if that patient ends up in a facility that is not his usual place to get care (and especially if he is unconscious and cannot provide critical information like allergies and PECs), so that the providers treating him can still do so with safety. This is becoming possible as health care systems upgrade to clinical information systems. It just takes the state governments to allow this information sharing to occur. Once that's done, it makes it a lot easier for patients to get treated outside of their own communities and eventually anywhere in this country.

Miulang

[brianca]

Re: Scarcity of specialists creating local crisis

what makes it harder to support a doctor here than in even more expensive places on the mainland?

[Miulang]

Re: Scarcity of specialists creating local crisis

what makes it harder to support a doctor here than in even more expensive places on the mainland?

The higher cost of living, the cost of malpractice insurance and the reimbursement rates are the main culprits. I think HMO doctors have it better than fee for service docs because HMO docs don't have to pay for their office, get their malpractice insurance covered by the HMO, they get a regular salary. their staff is paid for by the HMO and they don't have to be on call as often.

Miulang

[WindwardOahuRN]

Re: Scarcity of specialists creating local crisis

I never said the military provide a medical ship for the state, only suggested perhaps procur one from them, considering the military constantly decommissions older vessels. As to who procurs one, I dunno, whoever usually builds a land based hospital? HMO? State?

Telemedicine is definitely one area that should be pushed but I think it still has a long way to go when you need the full amenities. I would guess a bean counter is needed to crunch the numbers. You can't compare a medical ship to just one physical hospital but rather to all the supposed number of hospitals you need to staff and build out on the neighbor islands. Then we can see if a med ship is viable or not.

I think that one has to approach such an idea with the realization that Hawaii is not a third-world country nor is it in a combat zone. It simply does not warrant such a huge outlay of expense as would be incurred with a medical ship. It's the money, honey.

Good medical care, believe it or not, is much more accessible in the islands than on many parts of the rural mainland. In many rural areas of the western U.S., for example, routine health care is damn near non-existent. Alaska? Yikes. Many residents of that state would feel truly blessed if medical specialists were available for only a $39/hour-long plane ride.

I know many doctors here who travel to the neighbor islands on a regular basis to staff clinics, especially nephrologists. With the rate of kidney disease in this state it is an absolute necessity. This is how the shortage of specialists is dealt with here.

Can you make an appointment with an excellent skin cancer specialist who is adept at the latest methods of skin cancer treatment (and has the equipment to practice those methods) on the Big Island? No, but you can see one in Honolulu. Is it inconvenient? Yes, of course. But the treatment is available.

One area that has yet to be fully appreciated here is the use of Nurse Practitioners. Do not get me started on the Ol' Boy Network of docs here who are vehemently opposed to them.

They are widely used in many rural areas of the U.S. Appalachia, the rural South, Indian reservations and other classicly underserved areas.

[Miulang]

Re: Scarcity of specialists creating local crisis

One area that has yet to be fully appreciated here is the use of Nurse Practitioners. Do not get me started on the Ol' Boy Network of docs here who are vehemently opposed to them.

They are widely used in many rural areas of the U.S. Appalachia, the rural South, Indian reservations and other classicly underserved areas.

That's probably very true in the fee for service arena. But NPs are used extensively in HMOs (to the dismay of the MAs and LPNs sometimes). The nice thing about NPs (at least the ones I've dealt with) is that they take more time with their patients than the docs do and they can do nearly everything a doc can do at less cost to the system. They make the doctors more efficient by allowing them to take on the more difficult cases.

The Republic of Tanzania was a model of this strategy about 30 years ago (rural China is, too). The government of Tanzania realized that for every MD they trained, they could train about 8 or 9 health workers who could treat about 90% of any ailments that might befall a patient. They practiced "cookbook medicine" but it was done well enough that they were able to maximize their healthcare resources very well. I don't know if this system still exists, though.

Miulang