 Aloha, welcome to health care in Hawaii. I'm your host, Josh Green, State Senator E.R. Dock, here in my scrubs today with a good friend, George Green, who's the president and CEO of the HAH, which is the Health Care Association of Hawaii. Good to see you, George. Thanks for having me, Senator. So one of my favorite people, George, it's very easy to talk to you. You have incredible expertise with a lot of our hospital teams, our hospital executives. Why don't you give people a brief overview so they remember what the HAH does? Sure. And again, thanks for the opportunity to be here today. We represent all of the hospitals in the state. We also represent the majority of the nursing facilities, home health, hospice, and durable medical equipment providers in the state. We've just expanded, and we're representing more and more of the assistant living facilities in the state as well. What we do primarily is advocacy for those organizations. We advocate for them at the state level with legislators such as yourself. And we also travel to Washington DC to work with our congressional delegation. And we also work with the relevant regulatory agencies, Department of Health, Department of Human Services, and primarily at the federal level, the Centers for Medicare and Medicaid Services, or CMS. That's a big job. How big is your team? How many people do you have with you? Now we have a total of 17 people. And that doesn't count the consultants that we have on hand to help us with things like our community health needs assessment and to help us with some of the work we're doing in DC. Great. It's incredible. Yeah, lots of great people around you and lots of responsibilities. Why don't we dive right in and talk about briefly the hospitals? How are our hospitals? How do they match up? Tossables in the mainland? I know you had a lot of California experience, and you've now had national experience, I think. How are we doing? We're doing really well. There's always areas where we can improve. But by and large, I would say when you look at the job that the hospitals are doing quality-wise and the services that they're providing for the communities around the state, we're just as good, if not better, than many other states across the country. One of the things that we've undertaken is a program called Partnership for Patients. And it's a health care engagement network. It's a program that was started by CMS out of DC. And it is focused in on quality improvement. And we have done a lot better than many states over this past three years with regard to our work in quality. And frankly, I have to say thank you to you and your fellow legislators. But as we started this journey on quality, we came to you all and asked you to protect the conversations of that quality committee so that people will be free to discuss some of the things that are going on and share best practices with the goal being to improve quality, and it's really helped. Right, thank you for mentioning that. Yeah, I think for people who are watching us, I think they need to realize that when you say protect that conversation, that's so people can be candid when we, as doctors or hospitalists or administrators, if there are challenges, if there are even mistakes or outcomes that are bad for patients, we want to learn and want to be better. And you guys were really terrific because right from the get go, the health care association, you specifically, we're able to recognize that quality questions were going to be the kind of the tune of this decade. And that has played out that way. And so by informing us that way and getting that protected conversation, which you guys recommended, I think Hawaii has been out kind of ahead of the crowd. Absolutely, absolutely. You do a lot of stuff there. I mean, I want to dive into some of the other processes that you've taken up. Community help, community needs assessment, right? This was something new three or four years ago that you initiated. Yes, it's actually a mandate of the Affordable Care Act that individual hospitals have to go out and every three years conduct a needs assessment of the communities that they're serving. And the idea there is that once they go through this assessment process, which requires them to look at data, requires them to go through an interview process and requires them to place evaluations out there for the community to respond to and stakeholders in the community, they identify the top health needs of that community that they're serving. And then over the next three years, they target their community benefits programs to work with stakeholders such as the state, different nonprofits in the community to try and improve those health issues for populations that are most at risk. And where we're really unique is that although it's a requirement on all hospitals, the Affordable Care Act never said that you can't band together and do it as a state or do it regionally or for us do it by island. And so we've actually become one of only two states in the entire country to develop a statewide community health needs assessment. And we break it down by island. So we have one overall needs assessment, but then that information can be broken down by island. And then from there, that information can actually be broken down for each individual hospital. So again, Hawaii's a leader because our hospital leaders have come together and said, look, we're a collaborative group. We're a collaborative state. We're a small state. So we should do this together to try and improve health across the state. Oh, it was smart. Because I just from experiences past weekend, I did a three day shift and, you know, I'm transferring from a critical access small hospital on Big Island, transferring a patient over to Queens, doing it seamlessly. I know what resources they have. They know what the limitations that we may have on the neighbor islands. But because of this collaboration, small state, but island state, people are getting together. So again, it's terrific. What are some of our top needs? What came out of the assessments? Well, as you would imagine, to not to go through the laundry list, behavioral health is a huge challenge all across the state. Diabetes is a huge challenge across the state. You've got cardiac issues in various communities. And then asthma is an issue across the state as well. And then when you take a step back and look at the overall pictures, and specifically for the neighbor islands, as you mentioned, the overall issue of access to care in some of the communities on our neighbor islands get bubbled up as a huge issue for us. Yeah, it's, it really, I'm always happy to hear it kind of reiterated and confirmed because frankly, that's, that is what we've got. I had a case the other day, a very sweet person who needed placement because she had fallen in with the wrong person, young person, she had drug addiction issues. The case managers needed to get her to safety. We didn't have beds available immediately. That fell right into the behavioral health category and drug issues and a lot of interpersonal conflict stuff. And there's a lot of room to improve and grow there. Yeah, it's really a tough issue because you say behavioral health or mental health, but it is substance abuse. A lot of times it dovetails with the homeless issue that we have here. And so it's a really complex issue. And one of the things that we're doing in working with the state and some of their goals with regard to improving the homeless and behavioral health issue is reaching out to other states where they have different models in place where providers are working with organizations such as the state and other community stakeholders and figuring out what would work best for our state. Cause there are some models out there that have worked in different smaller communities. So, but it's really a tough issue to take on. It is. Each individual that you try to help, there are so many barriers and breaking through any mental health concerns and pathology, just the illness itself, one of the toughest disease states to work on. But really it's a person that you're dealing with right in front of you and you're rolling the dice. Even if you have all the services, the success rate is low. It's interesting, I think it's probably worth mentioning that one of your former protégés who kind of contra teeth I guess in healthcare, Rachel Wong is now the Human Services Director. So that kind of, I would assume that kind of relationship and that's a helpful history to have. Yeah, I mean, having Rachel over DHS has been extremely helpful. Our partnership with them over the years has only grown and only improved and some of the programs that we're working on, it's key for us to have a good relationship with them. So when Rachel was presented with that opportunity and she decided to step up to that challenge, frankly, and take on that large department, we couldn't have been more proud or happy for her and she's doing a fantastic job. Well, it's gotta be nice whenever you see someone that was part of your staff mature into a different position and have a different role. That's really cool. So you said behavioral health, definitely. I'm understanding that as much as 70% of those who are homeless in our community have some component of behavioral health challenges. So that's gotta be a big part of the solution for the EGA administration, all of us. Diabetes? Yeah, diabetes, as you would imagine. I remember when I came here, the first few weeks when I came here seven years ago now, I was in a taxi and I was explaining to the taxi driver what I did and he began to tell me about his issues with diabetes and I asked him the last time he went to go check, get a checkup, does he have a primary care physician? And they answered both of those questions. One was, I can't remember the last time I went to a doctor and no, I don't have a primary care physician. And so that's part of the problem here because we need to educate people and we need to get out in front of the disease before they become so acute that they end up in the hospital and there are serious complications that then they have to deal with for the rest of their life, but there's an extremely high percentage of diabetes across the islands. Yeah, it's a crisis really because it's both the crisis of too many people with diabetes which is happening nationwide. And then the fact that you can't find a provider sometimes and our shortage, I think Kelly Withee speaks about that quite eloquently as she's one of our partners, right? And so she continuously demonstrates that we're 20 to 22% short, trying to fill the gap in, but it's a big challenge. It is a big challenge and I know in my time here, you've continually tried to chop down that tree as it were with some of the legislation that you've introduced things such as loan forgiveness and it's gonna be a continual issue and we as a community have to work to try and make sure we have enough physicians here to support the needs of the communities across the state. Yeah, if it doesn't happen even in our state, I'm hoping to at least weigh in at the next presidential level and see if they won't help us with a national plan because I don't know if we wanna even spell it out as national service, although I wouldn't mind, but there's such a need now in almost all the states, I think you would agree that all the states, especially those that are rural, have this problem. Yeah, yeah, there's no question about it. You look at the rural areas even, not just the rural states across the country, they all have workforce challenges and physicians key component, but it's across the workforce for healthcare and so it's an issue that we've gotta tackle. We need to be working with departments of education and universities and community colleges to try and even all the way down into high schools to try and educate people about the profession of healthcare. It's a challenging profession, but it has amazing rewards. And I think the more that we can educate people at an early age, hopefully we can generate more people who dedicate their lives to working in healthcare. Yeah, well, this is not necessarily a PSA, but if you're watching out there and you're young, go into healthcare, become a nurse, become a nurse practitioner, a physician assistant or a doc, become a hospital administrator, get into healthcare because you will find a job in the state of Hawaii. Oh, there's no question. There's always gonna be employment in healthcare. It's one of the things that people are always gonna need. And again, we have to start looking at this as preventative and educational so that people can take charge of their own healthcare, but there'll always be work in the field of healthcare. Just 17 positions right in your office. Yeah, that's right. So okay, the community needs assessment. When's the next one due? We're just starting, hospitals are turning in the information to the feds this year from the last community health needs assessment. And so early next year we'll start the process and they're not due until three years from now, but we start the process early and get at it often so that we can identify those issues and then hopefully pull people together early to target some priorities where we can share resources and really create synergy to work on those issues together so next year we'll pull that group together. If people wanted to read it or see it, is there a place online? We have our executive summary which is at our website, which is www.hah.org. And anyone's free to log on there and not even log on. You can just go into the website and look at our reports and they should be able to get a copy of our executive summary. I'd recommend people do that because I get a lot of reports, but that is one of the valuable ones that I see it. It's very well thought out. It's extremely collaborative. And I'll tell you, if someone wants the overview of healthcare challenges in the state of Hawaii, that's definitely, should be their first read. Yeah, it's a great manual to go to. You know, as you've said, Senator, for anyone just wanting to sort of look at the environment for healthcare as far as what the health issues are, it's a great document to look at. So it'll give you some great ideas as to the challenges we're facing across the state. It's excellent. Well, let's see, you've got an annual event coming up. What's that about? We do, we do. And this is probably the best thing we do every year. It's our annual awards dinner. And again, I'm happy to be sitting here as one of our former legislator of the year, award winners, Senator Green. It's a night where we really honor those who are working on the front lines of healthcare. And this is everyone from housekeeping to all the way up to the docs, all the way up to administrators of facilities. And really what it does is it recognizes the fact that day in, day out, no matter the challenges, they are working to improve healthcare for the patients that they're serving. And everyone in any sort of healthcare facility and even those around the healthcare facility are eligible to be nominated. Some of the nominations come from within the field. But some of the nominations for what we call our healthcare heroes come from patients and their families who have had a great experience in a facility. And so it's great because number one, once the award winners are identified, we get to go out and surprise them to let them know that they're winning this award. And oftentimes they're just in shock. They've never been recognized in this way before. It's all videoed. And then we have to ask them to come to the event, which this year is October 29th at the Coal Al Ballrooms. And they oftentimes don't want to come. No, I don't want to be recognized publicly because we usually have around 500 people at this event. And they've never been in front of a crowd like that. More often than not, we're able to get them to come. And when they receive that reward and they're in front of their family and their peers and this huge group of caring people, there's not a dry eye in the room by the end of the night. And it's all worth it. It's all warranted because again, these are the individuals who actually touch patients on an annual day. And when I say that, I mean, these are the people that are providing them with food, checking their diet, changing their laundry, the doctors that are taking care of them, the nurses that are taking care of them, the lab techs, the rat techs, the people who are being creative and coming up with programs to build around them so that they can be healthy and whole once they leave whatever facility they're in. And again, these individuals never receive this sort of recognition. So for me, it's one of the best things that we do and it's the best night of the year because this is what healthcare is all about. I love it. I think that's a great place for us to take our break. When we come back, healthcare in Hawaii, I'm joined today by George Green, who is the president CEO of Healthcare Association. He has an award ceremony coming up, recognizing those who are taking care of you out there in the community. Hi, I'm Steven Phillip Katz. I'm a licensed marriage and family therapist here in Hawaii and I'm the host of Shrink Wrap Hawaii which is on Tuesdays at three o'clock. Have a great summit, take care of your mental health. For a very healthy summer, watch Viva Hawaii. We are here live on Mondays at 3 p.m. and we bring guests like our best health coach, Elena Maganto, eat well and follow her tips. Viva la comida saludable. Aloha, this is Reg Baker with Business in Hawaii. We're a show that broadcasts every Thursday at two o'clock we would love to hear from you and you can reach us in several different ways. We have a hotline that you can call in at 415-871-2474 or you can email us at thinktechhawaii.com or you can tweet us at thinktechhi. Looking forward to hearing from you and seeing you on our next show. Aloha. Aloha, welcome back to healthcare in Hawaii. I'm your host, Josh Green from Big Island of Hawaii. Today I'm joined by George Green, long lost friend, family member perhaps, who runs the healthcare association of Hawaii. In our first segment, we were talking about the great stuff that HAH does, creates the basically community health needs assessment, talking about the greatest challenges we have in healthcare in the state, particularly for hospitals and long-term care facilities, but all of our health conditions. He recognizes healthcare leaders and contributors to actual patient care in the state, which is really kind of a heartfelt mahalo to those out there in healthcare. Does so many different things, helps represent the hospitals at the federal level and at the state level. So there's someone there who can decipher all the challenges, the new regulations, the quality programs that are out there, but you do so much more. George, you came to Hawaii seven years ago and initially put out a plan that now is law. It's from my perspective saving our hospitals to a large degree called the Sustainability Acts. Could you unpack that a little bit for us? Sure, sure. So Hawaii has historically had one of, if not the lowest Medicaid reimbursements in the country, and so that's the reimbursement that we receive from ultimately the federal government to take care of the Medicaid population. We also have one of the lowest Medicare reimbursements in the country, and it's something that thankfully our congressional delegation is aware of and is constantly working with us to improve. But when I came here seven years ago, we were going through pretty significant budget deficits at the state level. And we realized that given the financial situation that the state was in, we couldn't really go to the state and ask for improved Medicaid reimbursements. We had to do our part and we had to figure it out on our own as the state worked through those budget deficits, which by and large, thank goodness they have. Right. So we did a lot of research looking at what has been done in other states that had poor Medicaid reimbursement, and we uncovered a program that required state enacting legislation to take advantage of a federal program that would essentially match funds that are sent from the state to recognize the care provided to the Medicaid population. And this is at the hospital and long-term care facility level? Yeah, this is specifically for hospitals and nursing facilities. And so we went through probably about a year and a half's worth of due diligence. That due diligence was reaching out to other states and bringing back examples of where it was working really well, where it was working so-so, and where it frankly wasn't working that great. Right. And at the end of the day, through a lot of education and dialogue with the state legislature and with our members, we decided to try and enact this legislation. And frankly, Senator, you were one of our key champions as we went through what was a pretty difficult process in getting this legislation through the House, through the Senate, through conference, and sending it to then Governor Abercrombie. I remember, we had a few moments, right up to the last second. We literally up to the last second. This one hung in the balance, and I can't tell you how many days I would go back to our team and say, it's dead. It's alive. It's dead. But at the end of the day, again with major support from the legislature at that time, we were able to get this bill to Governor Abercrombie, and he signed it into law, and it has improved our Medicaid reimbursement to the point where, as you've noted, this is literally life's blood to some of the nursing facilities and hospitals in this state. The thing that's key is that even with this program, hospitals and nursing facilities still lose on providing care to the Medicaid population. And as you know, when you look at the reimbursement from Medicaid, just to give an example, prior to this program being in place, if it cost a hospital $1,000 to fix a broken leg, Medicaid was reimbursing that hospital $700. After this program has been put into place, hospitals are now receiving about $830. It still doesn't cover their cost, but it's better and allows them to focus on other programs, and frankly, in some cases, keep certain services afloat otherwise that aren't providing revenue generation for them, and in some cases, frankly, keep their doors open. So this has been a key program. It's been in place for four years. As you've mentioned with Director Wong in place, our relationship with DHS has been really, really good, and we're looking at the fifth iteration of this program or the fifth year of this program, and our dialogue with DHS is going really, really well. So I'm very much hopeful and believe that this program is gonna continue to benefit hospitals and the people that they're serving and nursing facilities. Maybe for a perspective, George, I think it's so valuable that you're able to explain that to people. How much money does that mean each year, on average, that comes to our hospitals and our nursing homes? For hospitals, so as I said, let's say there's about $70 million in care that's provided to the Medicaid population that ultimately is not reimbursed to a hospital. This program is able to bring about $45 to $50 million in any given year to make up that $70 million shortfall. So hospitals are left with still a $25 to $30 million shortfall, but prior to this program, it was $70 million that they were losing. For nursing facilities, it brings in about $10 million, which again makes up about $20, $25 million. But their overall shortfall being $20, $25 million, so it almost cuts in half. That's amazing. Yeah, I think that people need to kind of take a step back and look at the big picture and that is that without the program that you proposed, and really it was you guys, you specifically, I think we would have seen more hospitals go the way of HMC West. When West closed, it was just too late. Now, of course, we have a great partner in Queens and we're so honored to have them take over the responsibilities there, but had not your proposals come and borne fruit, I think that we would have seen a series of hospitals fall like dominoes. That would have been devastating to a lot of the different communities. Yeah, I will tell you that on the day that HMC East and West were set to close their doors, and you'll remember this, there were approximately 28 patients that they hadn't been able to find placement for. Yeah, I'm just talking about that. And many of those patients no longer had any sort of insurance coverage or their insurance coverage had run out. And to this day, I use this example as a testament to the way that our healthcare providers in this state for all of our warts, step up when the community needs it because within a week, each of those 28 patients had a home, had a facility that took them in to take care of them. In most cases, knowing that they weren't going to be reimbursed for that care, but, and that's what our healthcare providers do from my perspective, in the time of need or in any time of need, they put competition to the side, they put their payment or reimbursement to the side and they try and do what's best for the community. And you're absolutely correct that without this program in place, there may actually be some facilities that would close, but for sure there would be facilities that would have to shut down some services, which would mean even less access in the communities across the state. So it's a vital program, it's an important program. Thanks again to you for helping us through that process and helping us to educate legislators and continue to do so. Because as you know, when legislators change, we have to go in and go through the same process of educating them about this important program. So. And it was unique too, because that was something that was totally new and it was new, not just to them, but you had to really educate those who work in healthcare, there are a few of us that are at the Capitol and the administration. And that was a big lift that you were able to pull off. That alone, there's so many good things that the healthcare association does that we're only touching on a little bit today, but that new plan, that program, which brings in, like you just described, 50, $60 million in aggregate per year, every year that we would not have seen otherwise, that does make the difference. And I think it makes it easier for people to collaborate. I think that when you have very good people like Art over at Queens and Ray over at Hawaii Pacific Health and Marianne at Kaiser and so on and so forth, they do all intend to work together, Jarrus over at the medical school, everyone's working together, but when there's a little bit of breathing room, which is really what you were able to provide, it makes it easier for them to say, okay, let's pause for a moment. If we are gonna move some patients, let's not worry solely about economics, which they don't have to worry only about. We can also additionally focus on this crisis at hand. So when there's West closing or hospital going on divert or someone losing staff, sometimes we lose staff on the neighbor islands for psychiatry program here or OBGYN program there, we need someone else to step up. Yeah, and I think one of the key factors that we have to hone in on here and remind people of is that this important program, which brings these additional funds in from the feds, it doesn't require one state dollar of appropriation, it requires not one tax dollar from the citizens across this state. This is all revenue that comes from the feds and in fact the hospitals and the nursing facilities have to take from their general operations in order to utilize this program. And trust me in the beginning, they were scared, they were just giving money a way that they did not have to give away because the way the program works is this money is put up and then the feds match it and then it comes back. But thankfully the program has worked. But again, when we get into these conversations, I would be remiss if I didn't remind your audience that this is not costing them one tax dollar and really isn't costing the state any money. And in fact, it generates revenue for the state to the tune of about all in 10 to $12 million a year. So it's a program that's a win-win for everyone without the state or the public having much to get in the game. That's great. Just a few minutes left. I wanted to touch on preparedness for natural disasters and you guys deserve a lot of credit. You stepped up when we had the concern about Ebola and other infectious diseases. Could you comment a little bit about what healthcare association does in that area? Sure. So we are the organization that runs what's called the emergency preparedness program. And we receive grant funding from the feds to handle developing caches of supplies across the state so that if there was a manmade or natural disaster, we could literally stand up hospitals if needed in order to take care of patients. We also provide training to all of the healthcare providers across the state as to how they should operationalize if there were a manmade or natural disaster. We even have programs in place now to educate about active shooter situations. And then in the event of a natural or manmade disaster, we have a volunteer workforce led by grant funded staff that operationalize and actually get in there and help with all the patients, all the facilities, all the communications hand in hand with the state, city and counties to manage any sort of disaster situation. So it's just, you know, I know we have very few minutes left in our program, just a few seconds, but I wanted people to know that there's someone out there working on our hospitals, our long-term care facilities, trying to keep these facilities up and running to provide healthcare services, but also if God forbid we ever have a severe need, got some experts there. Yep, we've got a great team in place. Okay, well, thank you George for joining me. Thank you for running the healthcare association. Yeah, thanks Josh. And we'll have you back again to talk about these health heroes in our community. Absolutely, thanks for the opportunity. You bet. This is Josh Green, healthcare in Hawaii. I've been George, joined today by George Green, who's our executive CEO and president of the healthcare association. Thanks for joining us.