In 2009, the Hawai‘i Legislature passed Act 18 to give policymakers a detailed understanding of the physician workforce in Hawai‘i through 2020. A $60 surcharge was added to the physician relicensing fee to fund the assessment project and in collaboration with the Hawai‘i Department of Commerce and Consumer Affairs a web-based survey was incorporated into the relicensing process that asked physicians about their specialty, practice location(s), and hours worked. The Hawai‘i Physician Workforce Research Team (HiPWRT) at the John A. Burns School of Medicine (JABSOM) Area Health Education Center (AHEC) is now able to track the physician workforce and determine trends and effectiveness of interventions. The report to the legislature can be accessed at www.ahec.hawaii.edu/workforce.html. The purpose of this edition of the Hawai‘i Journal of Medicine & Public Health (HJMPH) is to provide information on the work that is currently underway to mitigate the physician workforce shortages identified in the assessment.
The JABSOM HiPWRT study found that Hawai‘i currently is short 600 physicians when compared to similar communities across the United States. Statewide, about half of the shortage is in primary care and the neighbor islands suffer a disproportionate shortage compared to O‘ahu. A number of articles describing research studying the physician workforce are included in this edition of the HJMPH.
In addition to quantifying the shortage and maldistribution of physicians in Hawai‘i, the HiPWRT searched for possible solutions through focus groups, interviews, and literature reviews. At a June 2010 conference attended by 144 legislators, providers, educators, students, and community members, ten areas were identified as most urgent. They fall into four categories: Growing the Healthcare Workforce; Enhancing Practice Sustainability; Engaging Consumers & Communities; and Redesigning the Healthcare Delivery System. These are outlined below with descriptions of ongoing activities.
Growing the Healthcare Workforce
Expand pipeline programs — health career orientation, internships, training, and mentoring are being expanded on all neighbor islands by the Hawai‘i/Pacific Basin Area Health Education Center (AHEC) and other programs in Hawai‘i. A resource guide is being developed by the Hawai‘i Department of Labor and Industrial Relations for students in Hawai‘i to find information about available educational opportunities. This comprehensive listing will be available on a dedicated website soon and until then some resources are available at www.ahec.hawaii.edu.
Target training to meet the specific needs identified - training programs in rural areas draw students to practice there. The John A. Burns School of Medicine (JABSOM) and A.T. Stills University branch at the Waianae Coast Comprehensive Health Center have expanded rural training opportunities for medical students. The University of Hawai‘i School of Nursing and Dental Hygiene (UH SONDH) is providing advanced practice registered nurse (APRN) training in rural areas, and the Pacific University Physician Assistant training program in Oregon has created a track for Hawai‘i students to do their clinical rotations locally. Student reflections on a rural experience are included in this issue (Dilcher article).
Enhancing Practice Sustainability
Medical malpractice reform — legislation that revises the Medical Claims Conciliation Panel has been proposed by a workgroup of physicians and lawyers that has been meeting over the past year; HB 1967 and SB2469 have been introduced in the 2012 Hawai‘i State Legislature for consideration. This legislation would decrease the MCCP panel size to one doctor and one lawyer, increase the pay to each slightly, rename it the Medical Inquiry and Conciliation Panel indicating that patients can inquire and receive information from the panel before filing a claim of medical malpractice, and make the process less adversarial and without judgments of damages.
Reimbursement reform — this is underway both nationally and locally. The initial thrust of the reforms has been to support basic features of the Patient Centered Medical Home (PCMH). Other reimbursement models have appeared in the literature, but their applicability to the Hawai‘i delivery system is not clear (see Sakamoto article).
This spring the JABSOM HiPWRT will convene a conference for providers, educators, community members, legislators, insurers, and others to address PCMH implementation for solo and small group practices. The conference will provide continuing education on PCMH requirements including information for physicians on the practical business aspects of PCMH, care coordination and meeting meaningful use criteria regarding electronic medical records. See www.ahec.hawaii.edu for more information.
Rural payment differential — two insurers in Hawai‘i provide a 10% higher reimbursement for providers in rural areas and the idea has been discussed with the other insurers. The effects of the present differential will be studied.
Engaging Consumers & Communities
Community integration in recruitment and retention — the HiPWRT is partnering with Hawai‘i State Rural Health Association (HSRHA) to bring educational resources to communities, as well as working with projects such as the Beacon grant on the Big Island. The Beacon project has dedicated significant resources outside of the healthcare system to encourage local community initiatives to improve healthy eating, physical activity, and prevention of tobacco use. The Beacon project is also launching significant system re-design, including an island-wide approach to improve care for high risk, medically complex patients with chronic disease.
Redesigning the Healthcare Delivery System
Nationally it is recommended that we convert to a “team approach” to primary care that includes the full spectrum of healthcare professionals working together to meet the health challenges faced. Many of Hawai‘i's large group practices have or are in the process of converting to the Patient Centered Medical Home (PCMH) model, but it is very challenging for a solo or small group practice to do this with severe resource limitations. Therefore, the April PCMH conference is designed to assist with incorporating PCMH features into a small private practice by focusing on teamwork with non-physician clinicians, patient empowerment, care coordination and the use of Health Information Technology in this environment.
To this end, the increased acceptance of non-physician clinicians will be essential for providing care using the PCMH model, particularly in areas with a shortage of physicians. Yet Hawai‘i's use of nurse practitioners and physician assistants has been significantly less than is typically seen across the United States. JABSOM and UH SONDH have developed an interdisciplinary training program. The early impact of this program is described below by Michelle Yamada, president of the UH SONDH class of 2014:
Through juggling various-sized balls with medical students and acting out a scene of a car-crash victim, my nursing classmates and I practiced working together with medical students. My viewpoint of doctors as being elevated much higher than nurses changed. Instead of viewing medical students with the slightly fearful ‘awe of doctors’ I had before the workshop, I focused on collaborating with them as another branch of highly skilled healthcare professionals. Together we learned many valuable lessons about how one small slip in communication between members of the healthcare team can result in losing a patient, and we cemented those concepts through several fun and memorable exercises. I believe that all future healthcare providers should have similar opportunities to practice the importance of communication. In this way, we can work to prevent medical errors and save more lives!
Administrative simplification (paperwork reduction) — the HiPWRT recognizes this as a potentially important step in reducing the daily frustrations of running a busy practice. Furthermore, preventing premature retirement of our clinicians will help mitigate the projected shortfalls. The HiPWRT team has met with many of the local insurers to explore the different possibilities. Many of these ideas are discussed in the Sakamoto article and are being considered by our Hawai‘i carriers. If you would like to voice your opinion about the most burdensome paperwork challenges, please complete the short survey at http://www.surveymonkey.com/s/HJDBDP2.
Electronic health records statewide — the HiPWRT supports the Hawai‘i Health information Exchange's (HHIE) and the Beacon grant's efforts to aid clinicians in choosing and implementing an electronic health record. This will be emphasized at the upcoming PCMH conference.
The HiPWRT hopes that this edition of the HJMPH provides ideas about solutions to healthcare workforce shortages in the State of Hawai‘i. More information is available at www.ahec.hawaii.edu/workforce.html. Please contact Dr. Kelley Withy (withy@hawaii.edu) with your thoughts and comments.