 and welcome to Hawaii Together on the Think Tech Hawaii Broadcast Network. I'm your host, Kaylee Iakena. My guest today is Dr. Scott Grossgroitz. He's practiced radiology on Hawaii Island for almost three decades. Scott's also an active member of the Hawaii Physician Shortage Crisis Task Force. Now, as I'm sure many of you are aware, Hawaii has an acute physician shortage and is in need of thousands of healthcare workers. On our neighbor islands especially, where Scott resides and practices, needs shortages are especially concerning, since delays can often mean life or death situations. Scott joins me today to discuss the state's healthcare crisis. And we're also gonna talk about what steps legislators can take to address it. Thanks for joining me today, Scott Grossgroitz. Glad to have you on the program again. It's nice to be here again, professor. Thank you for the invitation. Well, first of all, tell me a little bit about your own background and specifically how you got involved with the Hawaii Physician Shortage Crisis Task Force. Well, I've been living in Hilo since 1993 and providing care in the community at the hospitals. And I served as the Chief of Staff at the Hilo Medical Center. And it became clear many years ago that we had a constant and chronic shortage of healthcare providers in far too many areas. And this shortage of healthcare providers has been documented by the Area Health Education Center at the University of Hawaii. The projections of physician shortages have been anywhere from 800 to 1,000 over the last several years, depending on the methodology that they use. But it goes beyond that. We also have severe shortages of APRNs and PAs who are a critical part of our primary care provider workforce here on the Big Island and on the neighbor islands. We also have a severe shortage of nurses. And so this has impacted the care of many patients and recent access to healthcare study by Community First and the Hawaii Rural Health Association did document many people are having a real problem accessing healthcare on the neighbor islands. And many were actually thinking of moving just to be able to get better access to healthcare, which is a problem. So Scott, you're saying that it's not just a shortage of physicians. It's a shortage of nurses and other staff as well. And on the neighbor islands, it's especially acute. Now I've heard stories that our neighbor island friends simply can't get an appointment with a specialist and have to fly to Oahu or to the mainland quite frequently. How bad is it, especially where you are on the Big Island? Well, it's fairly significant. Our shortage of physicians has been calculated to be 40 to 50% for the last several years. And that certainly feels about right. We know that many of the APRNs and MTAs we work with are also stretched thin with very large patient panels. People are burning the candle with both ends and often doing 60, 70 hour work weeks trying to keep up with the amount of work that needs to be done for our patients. And it's still not enough. And historically, I guess the idea would be you would have kind of more assets and resources on Oahu which is to be expected for a big city, but that you would fly as many people as possible. But that is extremely expensive to fly people. And then recently, due to a tragedy, the air ambulance system was suspended. And so people couldn't get off the island. So the lesson here is that we need to develop the healthcare systems at our neighbor islands so that we can take care of our neighbors appropriately here locally, as often as medically practical and reasonable. Now you just mentioned an air ambulance crash recently. Tell me a little bit more about that and what it exposed about the vulnerability of patients on neighbor islands. Well, over the years, especially when I was working closely at the emergency room, the Hilo Medical Center, doing a lot of trauma reads there, they're just for many, many patients that we saw that needed to be transferred right away. I mean, and that's because we didn't have the resources in-house to take care of them. Certain medical conditions like trauma and stroke and heart attacks, time is money. You either fix it now or else often there's no chance to repair the damage later. So when we can't move people quickly with their ambulance, we've had some bad outcomes over the years. And these folks are on their ambulance that they're doing a wonderful job. They are parolic in many ways. And I think many times because of the need to get patients elsewhere for treatment, they fly in conditions that normally they probably would not prefer to fly in, and that has its risks. So there was a recent flight going from Maui to North Wai area that crashed unfortunately and caused suspension of air ambulance services for a period of time. Well, it would seem that if we could solve the shortage of medical personnel, we wouldn't have to depend upon flying people from island to island or even to the mainland. But let's get back to the problem itself of the shortage. As you and I have discussed on many occasions, there are a lot of factors that are involved. It's not just one single causality, ranging from the retirement rate of physicians and the things that are actually incentivized earlier retirements than otherwise to the tax issues, Medicare reimbursement, as well as the overall cost of living in Hawaii. Let's take these item by item. And I know there's one that you might possibly be considering now, and that's retirement. Talk a little bit about that and how that's affecting the supply of medical personnel. We have a lot of folks that are kind of getting long in the tooth and they're practicing into their late 60s and 70s. In fact, a good percentage of our healthcare workforce is in that position. And so there's a whole cohort of people that are nearing retirement. And I mean, to be honest, I mean, usually people in healthcare, whether you're a doctor or nurse or whatever, usually not too much of whiners. We're used to hard work. We're used to lots of training. We're used to keeping your nose to the grindstone. But the hours that are required to try to keep up with the level of healthcare needs of the community, it's one thing to be working sleepless nights or 60 or 70 hour weeks when you're an intern, I guess to be a little bit more challenging when you're 60 or 65 or 70. To be honest, a lot of the younger people coming out of training wanna have more of a work-life balance and have more time for their family and that's understandable too. But I think the bottom line is there are, as a good portion of our healthcare force that's about ready to retire out. And we just don't have any replacements for those individuals. You talked about younger people and some of the goals that they have such as a more balanced work-life practice. But they're also facing other issues as well, cost of living. Sometimes people think doctors are just extremely highly paid individuals and shouldn't have to worry about the things that ordinary people do. But is that really the case, especially for people coming into practice or those in private practice and so forth and especially younger personnel who are entering the medical fields. How does the cost of living impact them here in Hawaii, everything from housing to food? Well, it impacts things a lot like it does for people in every job occupation or profession, but it gets to be a little bit more challenging, especially if folks have got very high debt loads from training. And just to give an example, my daughter, Malia, is born and raised in Hawaii. She wants to come back home. She's completed a dermatology residency. Now she's doing a Mohs surgery training fellowship where she'll learn how to remove skin cancers and do plastic type surgery to help people rebuild their faces or whatever after the cancers are removed. And so pretty rigorous stuff. Her and her physician husband have got a debt burden from college and medical school and things like that of about $400,000. And so, if she were to come back and try to say open up a private practice between paying off the debt burden that they have for education and paying for trying to get a house, there might not mean much money left, they would have access to for other things. For example, even helping build their practice or hire the necessary people. So, that's a real challenge. The cost of providing medical services like all services in Hawaii are the highest in the country by far. And the reimbursements for Medicare, Medicaid, local insurance companies are actually right near the bottom. And then the other challenge we have is that the state of Hawaii has a unique general excise tax on everything pretty much. And it's where the only state in America that taxes Medicare, tri-care, and Medicaid programs. And we're only one of two states that broadly tax healthcare. And so, anyway, that's a problem because if you often will break even caring for Medicare patients and you'll lose money caring for Medicaid patients. And then the state of Hawaii will come in and say, well, listen, we don't care whether you're losing money providing care for these folks who really need it. We're gonna still charge you a get tax on your gross income. And so, if you're already losing money the get tax just ensures that practices go into the red and often they have a hard time surviving in Hawaii. Now, when you talk about Medicare reimbursement and about the general excise tax that's imposed upon medical services we're really looking at the business aspect of medicine. And I don't think necessarily that most physicians and medical personnel went into the profession to do the business. But basically, it sounds like they're becoming overwhelmed by the cost of business especially if you're going to be in private practice. Now, we've seen a lot of people leave private practice or retire early or simply give up their aspirations. And that's a real hit to people who live on the neighbor islands where we don't have as extensive and availability of clinics and so forth. Talk a little bit about that how doctors and other personnel in private practice are especially impacted by the Medicare rates for reimbursement as well as the GET. Yeah, well the people in private practice that might be your family practitioner or APN or physician that you're seeing in their practice, they've come here they built their practice, they hired individuals they paid for all kinds of computer systems and things like that. And maybe hundreds of thousands of dollars or more in equipment so they could practice medicine. And in private practice here, it's just, it's very difficult. The state of Hawaii has, again these unique taxation models that nobody else in the country really has that put a tremendous burden on trying to stay afloat. Now, when it comes down to hospitals and hospital-employed physicians and nurses, Kaiser systems, things like that. All those other healthcare systems they're exempt from the get. In fact, the head of the Healthcare Association of Hawaii said that if the GET tax were applied to our islands hospitals, that many of them would have to reduce services or close their doors. And so we probably have about half of the healthcare providers in medicine in the state of Hawaii in private practice. But that number is decreasing pretty rapidly year by year. And again, the financial aspects play a great part of it. I used to really focus on how can we do the best job possible working with our colleagues in different disciplines and providing the best care we can for say breast cancer or other conditions. But recently it's become clear that we have to almost fight to be able to stay in business at all and probably provide any level of care. Now, Scott, you've been helpful toward our efforts at the Grassroot Institute to educate the public and lawmakers about what's going on in terms of the impact of the general excise tax on medical personnel. And you know that we're currently circulating a petition to the public that we're gonna present to the governor and lawmakers calling for exemption of medical services from the state general excise tax. Now, as you look at that, can you tell us a little bit more as to why that's so important to call for that kind of exemption and whether you think that that's feasible and possible during this upcoming legislative term? Well, I think I appreciate the Grassroots leadership in that area. It is completely possible and it's quite logical and it should happen. So when you take a look at things where we've got a documented worsening healthcare shortage that's been going on for several decades, you've got a national shortage of doctors and nurses that's gonna get worse. We have a harder time recruiting. You have a physician as a chief executive who wants to improve access to healthcare. That's Dr. Green. You have, you know, billion dollar surpluses in the budget as far as the eye could see. You know, it just seems to make a lot of sense to have a healthcare system that encourages people to come to Hawaii instead of practice, especially younger practitioners and that doesn't actually punitively push them out of the healthcare system. You know, basically what we're doing with some of these programs like Medicare, TriCare and Medicaid is that we're taxing patients and then the physicians are forced, they're basically paying their patients taxes for healthcare. So that, of course, is regressive, but it's kind of has the same sort of effect if you were to charge police officers for fighting crime or you were to charge firemen for fighting fires. It just, it makes absolutely no sense intellectually and it has very deleterious effects on the workforce. And one of the things that I think is a real tragedy is that as the number of people in private practice, which is the only area of medicine that's taxed by the get continues to decrease every year, Kalii, in a fairly short period of time, the amount of taxation from taxing, you know, doctors and nurses and APRs, that's going to go down a lot. You know, at some point it'll go down to zero, not right away, but it's kind of like having a flock of sheep that you used to, you know, for the wool and then you started throwing them on the barbecue, you know, for, it's pretty soon there's not a lot of the flock left to, you know, to be able to benefit, you know, from for the society. And so that that's my concern. During the COVID pandemic, we really saw our healthcare provider system stressed to the limit. It's not that the pandemic caused this shortage, it's that we had one going into it as you and I have talked about before. And the interesting thing is that we really felt the shortage of nurses and other healthcare professionals so much so that the state decided to go ahead and lift a regulation that it had, which before didn't permit out-of-state licensed healthcare professionals to practice here readily in Hawaii. And that was just so necessary. And people saw that we could actually benefit by allowing professionals trained in other states to come in and practice in Hawaii. What are your thoughts about turning that into a permanent feature of our healthcare practice over here? How much would that help us? I think it would help. Some, particularly when there's times of crisis, I believe Governor Ige this summer declared there was an immediate peril to public health when he basically waived state licensing, you know, for nurses to come to the state. And sometimes states will have a number of states put together and they'll have a pact and say, listen, if you're licensed in my state, and we know we've got rigorous standards that you, it's okay to practice in the other states within the pact. And I think that's as well worth looking at. So it's a solution. And I think that makes sense to pursue it. But more than anything else, we need to train up more young people who are local and we know we'll stay if they've got the opportunity and can have a fiscally viable practice here. And then just try to set up a situation where they can be successful. An important part of that is helping them live here in this economy. And doctors, they've invested a lot in their training, in their education, personally, financially, and they expect an appropriate reward financially. But many of them, as you and I have mentioned, find housing itself hard to afford. How related do you feel the issue of housing shortages to the difficulty of attracting new doctors and retaining recent graduates here in Hawaii? I think it's a big issue. There was a recent article in the Financial Times of London about housing in Hawaii and how that's impacting health access to healthcare. So it's big enough that it's catching the attention of major publications worldwide. From a personal point of view, we had a fantastic breast radiologist who is coming here basically to replace, to be my replacement, as I was supposed to retire, but he couldn't find a house that his wife could afford. And so they went back to the mainland. So it is a real thing. It does have a big impact. We've got to hit those problems together and indeed the entire complex of issues that makes it difficult for people to live here in Hawaii. Well, as we come to the close of our chat together today, what are some things we can do in the immediate future? What could our legislature act upon coming up that could help us to make some advancement in solving the problem of medical personnel shortage? Well, I think the low-hanging fruit here is the general excise tax, because again, to have to be the only place in the country that has this sort of tax set that discourages private practice, that's a fixable problem. The tax foundation of Hawaii and its president were very kind. They helped draft two general excise tax bills. One was for a broad exemption for doctors, nurses and APRNs. The other is more circumscribed just for federal programs of Medicare, Medicaid and TriCare. And we understand from some big island senators are gonna be introducing those to the Senate, which I think is a big plus. There was a bill that was introduced in the 2020 session that we helped try to put together was SB 2542 to exempt a general exemption for healthcare. And that actually passed the Senate by a vote of 25 to zero and then the House didn't hear it because the COVID pandemic hit and they limited the session. But I think the very fact that one of the two bodies in the state legislature was unanimously in favor of doing this for logical and practical reasons to improve access to care, I think that was encouraging to Lee. That's good to hear. I wanna make sure that our viewers understand the urgency of the situation we're talking about today. Tell us what you think Hawaii would be like in five or 10 years if we don't take the right steps now to stem off the medical personnel shortage. Well, we have, again, a very top-heavy workforce, with older and even senior providers, I'm of Medicare age and passed it already. So you're gonna see that cohort retire, they can't keep going on forever. And then you're gonna see that the deficits we have, and right now there's was a national study, the 3,000 counties in America. And the big island had the third worst shortage of healthcare providers in primary care. Maui had the fifth worst shortage of healthcare providers in America. And Kauai had the 13th worst shortage. And so as this huge cohort of maybe as much of a quarter to third of our providers retire the next three to five years, you're gonna find it almost, many people find it almost impossible, I think, to have their own family doctor or to get access for care or to get an OB-GYN. And that unfortunately, I mean, the real problem here is that is the fact that the healthcare providers are having a hard time. It says that if we can make a goal that we don't have enough people within our team, that the patients have access to care issues. And the Department of Health statistics show that the mortality or the death rate if you, for many conditions like stroke and heart attack, cancer and trauma and COPD and asthma and adolescent deaths and suicide is much higher, significantly higher on the neighbor islands than it is on Oahu where they tend to have more healthcare resources. Scott, those are some compelling thoughts. Any last word, if you were sitting down face to face with one of our legislators or our governor, what would you say? I would say to be bold here. I understand that there's, things are done a certain way and sometimes we are reluctant to proceed in fresh directions, but that the crisis is so real, so well documented and so impelling that something needs to be done now. It simply can't be deferred for several more years. So, one of the things we could do right now is try to get some level of tax relief to allow remaining healthcare systems and health practices to stay viable. And that in turn should help attract and us to have us attract younger providers coming out of training. And it should be reminded of course that all these training tracks for medicine that they're long, they're long for nursing, they're long for PAs, for physicians that's four years of college, four years of medical school, a year of internship, three to five years of residency. Then it takes off in another one, two years of fellowship. So, you've got almost like a 10 to 12 year track before people are even ready to put out their shingles or start providing services. So, there's just simply no time to delay. Well, that's a huge investment. Scott, thank you very much for being with us today. I appreciate your expertise. A pleasure. My guest today on Hawaii Together has been Scott Grosskoitz. He's with the Hawaii Physician Shortage Crisis Task Force and as always it understands the situation well and is able to explain it. We really have to do something about the physician crisis, shortage crisis as well as the shortage in personnel across the medical fields here in Hawaii. Thank you for being with us. You're watching Hawaii Together on the Think Tech Hawaii broadcast network. Until next time, aloha. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.