 Welcome back to Think Tech, I'm Jay Fidel. This is Community Matters. We're talking about the community today. We're gonna talk about Hawaii's doctor shortage and we're doing that with full understanding that the legislature begins very soon and there's some bills that could help. And to discuss the status of the doctor shortage, the healthcare shortage and the bills that could fix it is Scott Gross-Grenzies, a radiologist. We call him Dr. Scott. John Whyhay calls you Dr. Scott. And we're gonna discuss these things with him to catch up on what's been happening and what will happen hopefully one way or the other, and I suppose in the legislature in 2024. Welcome to the show, Scott. Thanks, it's a pleasure to be here, Jay. I remember the Hawaii provider shortage crisis task group, a group of medical, those in the medical leadership across the state, pretty much on every island. And we have docs and nurses and APRNs and PAs and yeah, we're trying to work together to find some solutions to the kind of the chronic access to care problem that Hawaii has. I wanna just say that it seems to me harder and harder to get an appointment with my primary or with any number of specialists. And I say to myself, okay, I can get through that. Nothing, there's no crisis here, but it takes longer. And then I say to myself, suppose this got worse then it would take longer still, wouldn't it? Or I wouldn't be able to do it within the time I need to do it to deal with the health issue. So I think we have a problem that everyone in the state at some level can understand, but do they? Well, there's plenty of information and data out there from National Surveys, Jay, that we do have some of the worst access to care in America. There was a Santa Benefit Study that took a look at how many people of each shade, what percentage live in a health professional shortage area. And that's where there's more than 3,000 persons per primary care provider. And Hawaii was far and away the worst. We had 35.6% of the Hawaii population last year in one of these health professional shortage areas. And that's over half a million people. And this is not like most states where you can get in your car and drive to the next city easily or the next state to see some place where you can find somebody to take care of your health care problem. When you have a problem, particularly in Hawaii's rural areas and the neighbor islands, it becomes very expensive to try to find someone on another island or fly to the mainland for care. So I see you, Scott, as the leader or at least one of the few doctors who is a leader to try to make the public aware, make the powers that be aware of this problem and try to fix it. Why are you doing that? Is it to make a lot more money? Well, I'm gonna get kind of long in the tooth here, Jay. I'm just about ready to hit 67 in a few months. And part of that is just selfish to be honest. As I get older and develop health care issues, I want to have somebody take care of me and my family. I see an awful lot of our patients that, especially on the neighbor islands, we have so many of us that are past retirement age still working because there's no one else to care for our patients, basically. And so a lot of my friends and neighbors will not have anyone to take care of them. And then I also have a daughter who's a dermatologist and surgical specialist that takes care of skin cancer and does plastic procedures to try to repair advanced cancers. And I would love for her to be able to come back to the state of Hawaii where, it made sense for her to do so. And so I've got a couple reasons that are selfish that I kind of want to see this thing fixed. Yeah, well, when you try to advocate to her to come back to Hawaii, we should all be in the room. And we should all be saying to her, come back, we love you, we want you. We'll make a path for you. We'll make a sweet career for you. We have to tell her that. Not only her, but all the people from Hawaii who went to medical school and all the people on the mainland who would like to practice in Hawaii. So I feel that there's a question as to whether we're offering her that kind of comfort. Are we? Well, we've made some progress in the last year. So Governor Josh Green and the legislature are taking serious steps with the urging of the University of Hawaii and others to expand the number of training slots with the Japs in medical school and also for nursing students, which is a good thing. And there's also some plans to help with loan repayment for healthcare professionals because often if you are in training, you can graduate with debt burdens that can easily exceed a quarter million dollars. And you have to pay those off. And so you have a lot of people coming out of, well, say you're becoming a medical specialist and you're gonna do your four years of college, your four years of medical school, your year of internship, your three to five years of residency, and often one to two years of fellowship. So you're not actually entering the workforce until you're in your thirties, your early thirties usually. And so at that point, you could be in debt hundreds of thousands of dollars. You don't have a diamond savings. You have nothing for retirement and you have to find a state or a place that you can work and earn enough to pay back all those medical loans and maybe put something away for retirement and also be fiscally viable. So one of the challenges that I see here is I think a lot of these things that are happening are very well intended and are a good start. I have a friend who's on the task force who's of native Hawaiian ancestry and she went through the University of Hawaii family residency program and actually trained with us in Hilo. So she was one of the residents that was there when I was there during my time as chief of staff and other working there. And so we, fantastic position, very hard working once to improve the local community and provide access to care. So over the last year, so when two of the senior family practice providers on the island of Molokai died, I think they were in their seventies or eighties and they died and there was a big deficit. So she went in on her initiative and started up a clinic, their primary care clinic. And unfortunately, she's telling us that it's very difficult to keep that open and the probability is quite high that that clinic will fiscally fail. So if we are encouraging our young people to go into training and to dedicate a decade and a half or more of their lives and to becoming healthcare professionals, and then we're encouraging them to go out to the rural areas and the neighbor islands to go to the communities that really need their care to have them go out and start that off and taking out additional loans of hundreds of thousands of dollars or more to start these clinics up and then have them financially fail. That just doesn't make a lot of sense. And that's one of the things we have to fix. Well, you know, it's interesting. It's not just that having a big loan out there that will follow you all the days of your life is a problem. And it's, I guess it's not just that you may not be able to get into medical school. It's that the whole picture to somebody graduating or even starting college, the possibility of being a doctor ain't so attractive. It really isn't so attractive. You have trouble making money, trouble doing business, trouble dealing with the bureaucracy, the loans. And it's no fun. I mean, unless you feel otherwise, you tell me, there's no fun being in medical school. It's like law school. It's not fun. So you have to go through a certain gauntlet to get there. And then you find it isn't fun practicing either. So my problem is this, you know, there was a time, I don't know if you remember, that people talked about Hawaii as the medical center of the Pacific, the kind of Mayo Clinic of the Pacific, where we would be awash in doctors and specialists. And they would come from continents around to take advantage of our medical expertise because we were awash in doctors and specialists. That isn't the case, is it? And I think we lost on that possibility. It's not here anymore. But it could be, should be, would be, don't you think? It could be. On the last year, we've had some conversations with Vicki Cayetano, when she was talking about some of the countries in the world that are basically, they have got top notch medical centers and programs and they've got enough excess that people come to that area for treatment, like medical tourism. And that's certainly possible. I mean, Hawaii's well positioned to do something like that. It's just basically having a business environment that allows you to have enough people first and take care of your own population and then other people that might wanna come here. And one of the things that has kind of happened that was reported by the University of Hawaii Area Health Education Center last year in the 2023 report was that there was a slight improvement in the number of doctors in Honolulu County where basically the shortage improved from 15% to 13%. But on the neighbor islands, it's gotten substantially worse. The number of doctors on Maui, it went from a 40% shortage to a 43% shortage. The big island went from a 37% shortage to a 41% shortage. Kauai went from a 26% shortage to a 30% shortage. And it's really tough to practice when you're missing a third to half of your doctors and especially we're short of APRNs and nurses and everybody else. And so it just, it puts a lot of stress on the system. And so while some things have gotten slightly better, we're still, we probably have about 3,000 providers or doctors that are working that are full-time equivalents and we're missing about 700 or more of those folks. And unfortunately, nobody lives forever and a lot of my colleagues on the neighbor islands are again, they're in their late 60s, they're 70s, sometimes 80s, and we're losing some of those folks. And that's unfortunate because there's just no replacement that's there for them. Yeah, and others leave town. That's part of the doctor shortage, isn't it? They get frustrated, they get disappointed, they take off, right? Yeah, I probably have seen at least 100 doctors and more nurses that have been on the big island during my time here that have come here, moved, been practicing, loved their patients, loved the area and they just couldn't make it work. And so they left. We just had the two largest urgent care and primary care centers on the North Shore of Kauai, a pretty isolated area. Both went bankrupt and closed their doors in the last, this fall. We had three medical clinics burned to the ground in the Maui fires. We have pretty much every larger physician group were on the big island of Hawaii is or clinic is in real trouble and may not be around long. I think it's quite possible that many of the small practices in private practice, small businesses, they're just not gonna make, maybe we'll make it work and we'll probably be gone in two to five years. But don't they consolidate? Don't they get picked up by the hospitals? Are the hospitals picking them up? Are the hospitals giving them a cloth mother, so to speak, to take care of them when they would like to leave the trouble of private practice and get under the wing of a hospital? Yes, some are. And actually, Jay, that's, I see that as a good trend. We've had a number of folks, one of our recent chiefs of staff at the hospital was a doctor who was a surgical specialist and she was losing money and basically was gonna leave the island and then Heel Medical Center was able to hire her and bring her on staff. So she stayed in Hawaii, which I think is a very grateful for the challenge though, of course, is about 67% of our rural hospitals are losing money or at financial risk. That's the highest level in the country. So many of our hospitals are in real danger, maybe having to close. And then of course, when these providers are hired by the hospital system, they're often losing money and they'll go to the state legislature and ask for taxpayer monies to keep them afloat for the next year. So it's some of it, it's kind of a, you know, you're just kind of playing a game or you're moving funds around because it isn't viable to practice in the state of Hawaii, which is unfortunate and it's unnecessary. And the reason that it's so difficult to practice here is, you know, the first thing of course, like every business, whether you're a hardware store or whether you're a grocery store, your costs are very high. The second is that the reimbursements from Medicare are rock bottom. They're right at the lowest. They don't take into account the fact that Hawaii is much more expensive to practice in than other states. And the same thing is true for local health insurance companies. They also pay some of the lowest rates in the country. In some cases, they're paying fee for service doctors and APRNs, et cetera, less than Medicare rates, which is basically a depth sentence in our state. And then finally, there's only two states in America that tax you substantially when you're sick or ill. So only New Mexico and the state of Hawaii tax you if you break your hip, if you're a senior or they tax you if your kid develops leukemia. Other states just don't do that. They consider that regressive. Often if you're sick yourself, you can't even pay your medical bills and the additional taxes. So other states don't do that. And then Hawaii is the only state in America that taxes Medicare, Medicaid and Tri-Care programs. And since those are not, generally those are not passed down to the patient. The healthcare providers absorb that. And so basically if you're taking care of say somebody on Medicare and you're breaking even or losing money, then the state comes in and goes, whatever you had it from your gross revenue for caring for that patient for repairing their heart fail or giving them a vaccine or whatever else it would be, we're gonna charge you whatever 4.5%. But that's on the gross and often that's like a 15 to 20% loss of net revenue. And that's enough to push a lot of practices into bankruptcy. You made a lot of points and I wanna respond to something with my reactions. The first reaction is we don't have a ferry and flying to a neighbor island is expensive. There are a lot of people who think that aside from the medical issue, life on the neighbor islands ain't bad. But when they address that issue for themselves, they say, I'm not doing it. I'm not going to the neighbor islands because when I get older, I'm gonna need healthcare and there isn't enough of it for me there. So I cut that decision, not gonna do it. This is tragic. It's tragic for the neighbor islands. They could have population as well as medical care and people finding comfort in the level of care. The other thing that the other reaction I have is that if you deplete the industry, the number of doctors and healthcare workers, then it just seems to me, and this is Aristotelian and symbolic logic I am giving you now. If you deplete the size of the industry, you are going to deplete the quality of healthcare for the individual member of the community. And so if you're a policy person, like a legislator or a governor or the director of the health department, what you have to do is you have to throw resources at this because it's mission critical. It's mission critical for the state, for the distribution of population around the state, for the good and welfare of everybody in the state, you must actually throw resources. And if you throw more resources at it, then you actually need that's okay because you have to get back to parity. You have to get back to the Mayo Clinic of the Pacific. At least you have to get back to a feeling of comfort and confidence by everybody in the state. We don't have that now. Yeah, and I think a growing number of our leadership in the state are starting to really think about this, Jay, and looking for solutions. We just had the state director of health development and planning agency shipped to Dr. John Lewin who goes by Jack Fulover and met with Mayor Mitch Ross a couple of weeks ago. And we had a very good conversation and basically we were just talking about those things. There's, Governor Green has got a goal not to have no shortage of doctors or nurses within his term. And I think that's highly commendable. It's just a question of how do you make that happen? We had Congresswoman Jill Takuta flew out to me with our tax force about 10 days ago. And I was very encouraged by her level of understanding of the problems that we're facing. So she's gonna be working as best she can in Washington, try to get Medicare rates up to the point where people can have a medical practice and not lose money. The other thing is both the Congresswoman and Dr. Lewin, they both strongly agreed that it just didn't make any sense at all to have the worst healthcare provider shortage in America. And then to be the only state that's taxing the providers into bankruptcy for caring for our seniors and those in economic need and our veterans, that just doesn't make any sense. And in last session, we did introduce, we helped to introduce some bills to basically exempt those areas of healthcare from the state's general excise tax and the Hawaii state Senate passed the bill without a unanimously in every house and Senate committee that heard the bill passed it without a no vote. That's the second time that's happened in the last several years. So you basically have unanimous support to pass these bills and they still don't pass. It's just, it's kind of mind boggling. And so it's a disgrace because obviously people need it, want it. The state needs it, wants it. Even most of the legislature needs it, wants it. And yet it doesn't pass. Very hard to understand and rectify that. So I assume that bill is gonna be back in play in only a few days in the 2024 legislature. Yeah, our understanding is that there's gonna be another bill introduced that's fairly much the same thing. Let's stop taxing people punitively so that they're unable to practice in the state of Hawaii. And the only committee that has refused to hear the bill was the state finance committee or the house finance committee rather where they declined to even hear the bill. I think if the bill was heard, there would be support and votes to pass it. But in the state of Hawaii committee, chairs can just simply kill any bill by refusing to even talk about the bill regardless of the level of support from other lawmakers and from the general population. So I hope that it's heard. I think the argument is just that if you give an exemption for one thing, you'll give an exemption for others even though there's numerous exemptions from the state general excise tax already on the books. And as a matter of fact, if you're a healthcare provider working for a federal health system or any of the hospitals we have in the state or for HMSA or for Kaiser, you're not taxed the get. So the only GE tax in the state is on primary care and private practice folks. Which is unfortunate. And of course the thing that just is very confusing is that once we eliminate all the small businesses that are providing medical care and dental care, particularly on the neighbor islands and on the North Shore of Oahu and the Leeward side. Once you eliminate all those providers and you push them into retirement or push them to leave the state, there will be no tax revenue from the get. There will be nobody left to tax. And of course, you'll also when those doctors and nurses leave, you'll lose the corporate taxes they were paying, the individual income tax, the property taxes, the get tax and everything that they would have bought every time they went to Costco. So it almost seems suicidal in my opinion because you're just, you're eliminating the tax worse while at the same time, you're eliminating a significant portion of the Hawaii healthcare system. It's tragic. And he was, I can't imagine why the finance committee wouldn't hear that bill. I hope you can put pressure on him. I hope somebody can, who is opposing it? Is it the tax people opposing it? Who in the world would oppose better medical care for the whole population? Who is that? Well, I don't think it's the department of taxation at this point. I mean, there's some confusion about this for many, many years that department of taxation on the website said that doctors and APRNs et cetera could take the GT tax and pass it on to their Medicare patients. Unfortunately, that's viewed by the federal government as Medicare fraud and we were able to have that dialogue and the department of taxation realized that that was a problem, that we can't be encouraging people to put their licenses at risk by doing that and getting involved in a fraud investigation. And they did submit testimony last year where they didn't oppose it. They said, this is how it would work and this would cost. And so they, I don't think that department of taxation is blocking it or opposing it at this point. I think it's just a matter of the House Finance Committee. Unlike the Senate Finance Committee, they just have decided not to ways and reasons. They have decided not to hear the bill. And to be honest, I think this is something where individual families need to weigh in on. You need to write the members and the chair of the House Finance Committee because if you have an OBGYN in private practice or your kids have a pediatrician or you've got an APRN or a doctor who's your primary care provider, you will probably not have that provider in just a few years, they'll probably gone. And write them to say, I like my doctor, I like my APRN or my PA. I want these people to continue to care for me. I want my kid to have a pediatrician. You know, there's such a shortage on the neighbor islands. There's many, especially specialties. There's many specialties or there's a 40 to 100% shortage on Maui and the Big Island especially where there's just nobody there. And unfortunately, what ends up happening is that we have a lot of members of our community that simply can't afford to fly, especially if you have to go many times, you know, over to Oahu to see, see somebody over there. And a lot of times they just don't see care at all. My friend who provides care on Molokai says a lot of the population there has just become, they just accepted it. They become fatalistic or stoic about it. We're like, listen, we just don't have care. We're gonna live and die here on this island. And many times there will be no one here to help us, which is, I mean, when you think about it, it's just tragic. It is tragic and the emphasis on the word die. They die early. They die in pain. They die without solutions that could be available elsewhere. And that's just awful. That's tragic. Life expectancy is affected. And let me say too, in terms of life expectancy, we have an hourglass bubble coming in where there's a lot of elderly people, people are getting older. They are everywhere. And for them, every dollar means something. For them, they get sick. For them, if they don't get care that helps them, they will die early. And it seems really tragic that we are not providing them, especially in the neighbor islands, with the care that they should have. I mean, to me, if I was a legislator, I'd be mighty impressed with that because no secret legislators get old, too. I think, Jay, you're familiar with the statistic that Hawaii has got the fifth worst population exodus in the US as a percent of population. So we're number five in people that are leaving the state. And there was in 2022, 15,000 people left the state of Hawaii. And some of them are younger or people with families and they needed to be able to find affordable housing or a job, but there's a fair number of people, too, on the neighbor islands where they go, listen, I'm getting older. A lot of these people are dedicated members of the community. They belong to Rotary. They're trying to help at hospice and things like that. But they go, listen, there's nobody here to take care of me and I'm not gonna mind or know that there isn't anybody. And so I'm gonna leave before I get sick or while I need care. And that's unfortunate. I'm a breast cancer specialist and breast cancer is really very treatable if you catch it in the early stages. I mean, the cure rate is fantastic, but if you wait too long and it spreads to the lymph nodes or the rest of the body, often we don't have the ability to cure that and often you're just buying time. And literally every week or two for the last couple of years I've been washing people, walking into the clinic. Some of them are older, but some of them are in their 30s and 40s and they've got palpable breast masses that they've known about for six months, 12 months or longer. And they say, well, I looked, I called 10 or 15 or 20 provider groups hoping that I could get an appointment and their panels are awful. I couldn't find a way to take care of me and sometimes they actually go into urgent care or ERs for evaluation of a breast mass. But unfortunately, a lot of these women after having their care put off because they couldn't access care in East Hawaii. By the time they come in, they've got lymph nodes that have got the disease in it. And that's a tough conversation to have with people when they're, especially if they're younger and they're in there and their kids are in the waiting room and you're trying to explain to somebody who's 42 or whatever that your cancer has spread to the lymph nodes and we'll do the best we can. But you kind of know that you can't often cure these individuals at least now with their current technology. And what tragedy on an individual patient scale and on a community scale seems to me though that you're doing a very important thing. You're talking about this, Scott. You're making people aware, not just the legislators and the health officials, but people in general, the public. And I think the public has to be aware, A, of the problem, B, how it affects them and their lives and their children who often leave because of this. And C, what can be done about it? So you mentioned the initiative to try to exempt medical services from the gross excise tax and maybe make it a little easier to do Medicare and Medicaid work. But what else? What else would you like to have? If I made you the king of health in the state of Hawaii with unlimited power, our power to reverse anything that anybody else did, what would you do? The first thing I'd do is, was just to, if you're in a hole, they always say the best thing to do is stop digging. So if we're losing people because of our tax structure, let's change it. I mean, if people have got a high income and you tax them with one of the highest personal income tax rates in the country, but don't prevent hospitals and medical practices from even being profitable in the first place. That's a recipe for disaster. And I think that one's kind of a no-brainer. The second thing is that a lot of people are saying that the level of administrative burden has just gotten way out of control. There was one recent study that was done which said that the majority of doctors in America were spending between 10 and 20 hours a week doing what's called prior authorization. And that's where they're seeing their patients or making decisions that we need this medication or recommending that this is the surgical course of action or we wanna have this rehabilitation process. These are people that have gone through tremendous levels of training. I mean, it exceeds out of an airline pile. When you take a look at the decades it takes to learn your craft in these areas. And then the insurance companies, they put all these prior authorizations which basically mean we're gonna second guess you. We're gonna second guess you if you wanna give this vaccine. We're gonna second guess you if you want this medicine. We're gonna second guess you if you're gonna support your patient in getting a hip replacement because they can't walk anymore because of your osteoarthritis. They're gonna second guess everything you do just basically to block it. And then at some point in time some of those will be approved. But if you are, I mean, I don't know anybody here that works a 40 hour work week. I mean, most people are working often 60 or more hours a week. Again, sometimes when they're into their 60s or 70s but if you're wasting 10 or 20 or 24 hours a week jumping through these administrative hopes that just doesn't make any sense. Now the American Medical Association put together what they call their model bill where it basically it's common sense kind of things. If it's an urgent thing and you do have a pre-authorization process in effect you have to basically make a decision within 48 hours. And these decisions that are made for patients in the state of Hawaii have to be made in the state of Hawaii by a doctor who's at least as well trained as the person that they're looking at. Often right now, if you're getting into denial they're sending it off to some ancillary person who may not even have very much medical trainings setting at a desk in New Jersey, blocking things for people in Hawaii. So we have asked the state legislature, the Senate Health and the House committees that are involved with healthcare to introduce the American Medical Association's prior authorization model bill. And we think that could be a very positive thing. It could, if you've got a huge shortage of healthcare providers why not make them as efficient as possible? And there's been a lot of studies that show that you're actually, you're not hurting care. You're gonna improve care for many of your patients if you allow them to get their care in a timely manner in conjunction with their healthcare professional needs, things they need. I want to know the thing before we go. And that is, I've heard from people in the mainland that they go get a doctor who will bypass all of that and the doctor will be on contract with them. And he will be available or she will be available many time and come and give them special attention, special treatment in the way of a primary, I suppose. At a fixed cost, that's not deductible. That's not part of insurance. You should just pay, I guess, annually. What do you think of that? Is that happening here? Is that worth considering? Can we encourage that? Or should we not encourage that? It is happening here. It's called concierge. Concierge, yeah. And exactly as you pointed out, rather than deal with all the insurance company hassles and the overhead that comes from running care through insurance companies, which take their Vega course sometimes pretty substantially. And instead, you just have a contract between you and the person taking care of you and they commit to take care of you and you pay them on a monthly basis, whatever. And so there's some of that taking place. And I think it does have its place. And it's a choice between healthcare providers who are unable to make it in our current system, if you're for service and they're leaving the state, I'd rather have them here and taking care of those patients who are able to come to these arrangements with them. The challenge, of course, is that we have, over half of our state's population is on Medicaid and Medicare, over half. And we have a large contingent of veterans in the state of Hawaii, which I'm one. And a lot of these folks, they cannot afford that extra out-of-pocket expense. And so while that might be a solution that's appropriate and reasonable for some providers and some professionals or patients, you can't write off the huge portion of our population that for which that's not available and who couldn't afford it, even if they wanted to do that. Yeah, we've got to think about the larger picture, the larger population, the larger sense of comfort and health and confidence in the future and the failure of the government to provide adequate healthcare personnel and services affects that. So I wish you good luck this session as all sessions and I hope you can advocate and find sympathy, if you will, with every legislator involved. Thank you very much, Scott, for coming on our show. I hope we can check back with you as the session unfolds and see how things are going. Well, I'm optimistic, Jay. We have a physician governor who, Dr. Josh Green, who's got eyes on this problem, is intimately familiar with it, having worked in primary care and urgent care centers on the Big Island. We have a lot of very smart people like Dr. Lewin of SHIPTA and Congresswoman Takuta that understand the problem and are helping us try to find solutions. The mayors I think are starting to come around and realize how important it is, even for their economy to have a functioning Bible healthcare system. And so, yeah, let's work together. Let's make it happen. Thank you, Scott. Back to Scott Grosskreuz. We really appreciate you coming on, Aloha. Aloha, Jay.