Hawaii’s physician shortage has loomed large for years but worsened in 2020 — and on the Big Island, the lack of doctors became even more dire.
A 2020 Hawaii Physician Workforce Assessment — completed by Dr. Kelley Withy, a professor at the University of Hawaii John A. Burns School of Medicine and a physician workforce researcher — found that Hawaii County is short 287 doctors and has 53% fewer physicians than similar-sized communities on the mainland.
That’s the largest shortage in the state.
Maui County has a 43% shortage, Kauai has a 33% shortage and Oahu has a 20% shortage. Statewide, there is a need for 29% more physicians.
The Big Island had a doctor shortage of 44% last year.
Ideally, Withy said, Hawaii County should have 539 physicians, but instead there are 270.
“We’ve gotten a lot worse in a hurry,” said Dr. Scott Grosskreutz, a Hilo radiologist who helped organize the Hawaii Physician Shortage Crisis Task Force.
The task force was formed two years ago to address the worsening shortage of doctors on Hawaii Island but has since grown to include members from all islands.
“In Hawaii, where the cost of providing services are high … a lot of practices are having a difficult time staying viable,” he said
According to the assessment, there are 2,812 full-time equivalent physicians in Hawaii, compared to the 3,529 physicians that are needed statewide.
However, the assessment finds there’s actually a shortage of more than 1,000 physicians statewide when factoring in the needs for specific islands and specific medical specialties.
Grosskreutz said the goal of the crisis task force is to make Hawaii a viable place to practice for younger health care providers.
But there’s difficulty in recruiting younger physicians, he said, which means the state is left with an older cohort of providers.
Many of these doctors, though, will have to retire soon, and there are few doctors to replace them, Grosskreutz said.
“We’re trying to recruit more doctors to come here, we’re trying to train more doctors locally, and we’re trying to keep the doctors we have desperately,” Withy said.
Nearly half of Hawaii’s physicians — 46% — are 55 or older, and 21% of doctors are already 65. One is 90.
In the past year, at least 110 retired, 139 have moved and 120 decreased work time.
Eight have died.
“The number of deaths have been up for the last two years,” Withy said. “If it was only this year, I would think it was COVID. It’s a clear indicator our physicians are aging out and working until they die.”
Grosskreutz, president of the Hawaii Radiological Society, echoed those sentiments.
“Many local doctors have deferred retirement working into their (late) 60s and 70s, while accepting the risk from the COVID pandemic,” he said. “A third of our remaining doctors on the Big Island are over the age of 65. These senior doctors simply cannot carry on much longer and need to be replaced by recruiting younger providers.”
According to Grosskreutz, the Big Island physician shortage soon will be approaching 300 doctors, and a 60% to 70% shortage of physicians is predicted for the near future.
No easy fix
But difficulties in the recruitment and retention of providers willing to live and practice in Hawaii are just one component of a complex and intertwined puzzle.
Reimbursement rates from insurance companies and Medicare and Medicaid, as well as high overhead and the state’s general excise tax on medical services, are among some of the factors that make it difficult to attract and keep health care providers here.
Dr. Matthew Dykema, a private practice family medicine physician, moved to Hawaii in 2012.
He worked at Bay Clinic for four years before joining an established practice, Joyful Living, in 2016. He took over the operation in 2017 from a retiring physician.
“As far as the (physician) shortage, it just means I have a lot of patients to try and take care of myself,” Dykema said. “Even though I’d like to bring on another provider, it’s challenging financially to do that, and … there isn’t anybody. It’s hard to incentivize people to move here if it’s not even going to be financially sustainable.”
Dykema, who is the sole provider at his practice, said there is a list of people who want to be patients, but the practice can only bring in new patients gradually as old patients leave or pass away.
But Dykema may be better off than some
He was on scholarship through the National Health Service Corps, which paid for his medical schooling in exchange for working in an underserved area for four years. Dykema said his work with the Bay Clinic counted toward that four-year commitment.
“I’m in a good position in that I don’t have a bunch of medical school loans and was prudent throughout undergrad,” he said. “… If I had a lot of debt from medical school, there’s no way I’d be able to practice medicine here. Not in private practice. … It’s just really challenging, when you have overhead costs and the (insurance) reimbursements are low, to make ends meet.”
The impact on health
Withy said the physician shortage can lead to a higher risk of untreated chronic illness and early mortality.
The Big Island, for example, doesn’t have a heart surgeon, neonatologist, endocrinologist or colorectal surgeons.
“Let’s say you had a baby born premature,” Withy said. “I would say the risk on the Big Island is more than if you’re at Kapiolani (Medical Center for Women and Children), where you have experienced neonatologists. And if you have a heart attack and need to have surgery right away, you would not get it.”
Likewise, Grosskreutz said, the lack of access to health care providers could result in higher mortality rates from other causes.
“For example, having a personal physician or health care provider has been shown to double the likelihood of a woman being screened for breast cancer with mammography, and on the Big Island, we are missing over half the needed doctors,” he said.
According to Withy, those working to combat the physician shortage will lose some financial support from the state “because the Legislature is not considering anything that will require general funds, even if it’s needed, like loan repayment.”
The state is facing at least a $1.4 billion budget shortfall due to the pandemic.
Withy said a loan repayment program has been in place since 2012, funded with a federal grant that requires a dollar-for-dollar match. For the last three years, the Legislature has been the primary funding source of the match, but can no longer afford it, she said.
Since its inception, there have been 52 loan repayment recipients. Withy said the current contracts will continue but new ones will not be awarded.
Lisa Rantz, president of the Hawaii Rural Health Association and executive director of Hilo Medical Center Foundation, however, said before former Mayor Harry Kim left office, the county awarded the foundation $100,000 for loan repayments for doctors in Hawaii County.
What’s next?
Withy said there is a lot that needs to be done to address the state’s physician shortage.
“If we could triple the size of the medical school and the residencies, that would be a long-term solution,” she said. “… The Big Island used to have the worst primary care shortage, then started the family medicine residency (program), and now they’re not the worst primary care shortage.”
But Withy said increasing physician pay and decreasing administrative burdens are the quickest ways to incentivize doctors to come here — and stay.
A bill to exempt health care services provided by doctors and primary care APRNs from the general excise tax was introduced in the last legislative session, which was cut short due to the COVID-19 pandemic.
Grosskreutz said the bill had passed the state Senate but was not voted on during the emergency session called last spring.
The task force will ask Big Island lawmakers and Mayor Mitch Roth to support introduction of a more focused bill in the upcoming session that will help recruit more health care providers to the neighbors islands to help care for the growing number of Medicare and Medicaid patients.
According to Grosskreutz, Hawaii is only one of two states that taxes health care services, and the only state that taxes Medicare benefits.
“We feel that taxing patients for their health care when they are sick or injured is socially unjust, particularly during global pandemic,” he said. “Often these patients are unable to work and struggling to care for their families.”
When addressing the doctor shortage, Rantz said, teamwork is key.
The Hilo Medical Center Foundation serves as the Big Island’s Area Health Education Center, which helps address the health career workforce pipeline.
“We have tremendous shortages, Maui has tremendous shortages. Molokai does, but if you can’t get a doctor to move there full time or they can’t afford a doctor full-time, then maybe one of our docs (could fly over),” Rantz said.
“So we have resources. We just need to allocate them better,” she said. “So by working together we can do that.”
For her part, Rantz said she’s not surprised by the Big Island’s growing physician shortage.
“I anticipate that number is going to increase, and it scares me for our community. I think we need to band together, and we need to let our government know — whether that’s our County Council, our mayors, our legislators at the state and federal level — that they need to address this. They need to help.
“Because not having access to care is not good for our community’s health.”
Email Stephanie Salmons at ssalmons@hawaiitribune-herald.com.