|Home | About | Journals | Submit | Contact Us | Français|
The challenges to healthcare delivery posed by Hawai‘i's unique geography, physician shortages, and dispersed population are of particular importance in light of implementing the Affordable Care Act (ACA). This study draws on central goals laid out in the ACA — to decrease costs, increase access, and improve patient outcomes. The use of the Patient-Centered Medical Homes (PCMHs) is a care model that has the potential to meet all three goals. How to identify the most effective way to develop PCMHs in the specific context of Hawai‘i is the focus of this study. To provide recommendations for effective PCMH formation, a qualitative review of previously compiled data from the Hawai‘i/Pacific Basin Area Health Education Center (AHEC) and phone interviews with six primary care providers throughout the islands were conducted. The results broadly suggest three paths towards the effective implementation of PCMHs in Hawai‘i. The first recommendation is to create a PCMH template or business model for physicians in order to ease the complexities of implementing such an elaborate system of care. The second two recommendations actually veer away from PCMH towards general interventions to increase care in rural Hawai‘i. Thus, the second recommendation is to create a specific track for becoming a rural practitioner at the John A. Burns School of Medicine (JABSOM) to increase the retention of physicians in underserved areas. And the final recommendation is to increase utilization of telemedicine techniques to overcome physician shortages and geographic challenges by allowing rural physicians to network with specialists on neighbor islands. These three strategies are all possible to accomplish with commitment and could be implemented to benefit the providers and rural population of Hawai‘i.
Hawai‘i faces many challenges in the ongoing development of its healthcare system. Current national trends in healthcare reform, as evidenced in the recent Affordable Care Act (ACA) legislation, include initiatives for lowering costs, improving quality, and providing better health outcomes. One method for reaching these objectives is the creation of Patient-Centered Medical Homes (PCMHs). PCMH's focus on improving care, coordinating services, reducing costs, and thereby improving conditions, which are especially relevant for the geographically-constrained regions and rural communities of Hawai‘i.1 This research explores what rural healthcare providers would need for effective adoption of a PCMH model to improve care in their areas. More specifically, this study suggests strategies to overcoming the interrelated effects of geography, low-density population areas, and physician shortages for the implementation of PCMHs in rural Hawai‘i.
Hawai‘i is geographically unique, comprised of islands spanning hundreds of miles across the Pacific Ocean. With the majority of the state's population living on the island of O‘ahu, there is a greater primary care physician (PCP) supply on O‘ahu as compared to the other Hawaiian Islands. There is a further discrepancy in the number of physician practices from county to county, with the greatest physician to patient ratio existing in the County of Honolulu on O‘ahu. Compared to the City and County of Honolulu, Kaua‘i and Maui Counties have a 3% greater demand for physicians and the County of Hawai‘i has a 6% greater demand for physicians.2 This unique geography makes the state of Hawai‘i difficult to compare to other locations.
Importantly, due to the nature of island geography, it is difficult for residents to access care if the provider type they need is not available within their community, or, in some cases, not on their island. If patients need specialty procedures or testing done that are uncommon or unavailable on their island, then they must fly to O‘ahu for those treatments. This can put a heavy financial burden on the patient or their legal guardian because not only will they need to pay for airline flights, but also for accommodations and transportation once on O‘ahu if they need to stay for longer than a day.
Given the topography of the Hawaiian Islands, obstacles to healthcare access are especially acute for residents living in rural areas. One of the largest barriers to access for residents is the geographic limitations imposed by being an archipelago in the central Pacific Ocean. Specifically, residents on neighbor islands have limited access to specialty services based out of O‘ahu, because specialists are typically located in urban areas with larger populations. According to the State of Hawaii Primary Care Needs Assessment, the neighbor islands are considered medically underserved areas/populations.3 Thus, for the purposes of this study, the researchers consider all neighbor islands rural to Honolulu.
In response to these issues, the ACA encourages physicians in rural areas to adopt PCMH models. Through adopting community-based collaborative care networks, quality health measures and loan forgiveness programs, rural providers are incentivized to embrace team-based healthcare.4 At present, there are 16 federally qualified health centers throughout the islands, serving the under and uninsured populations of Hawai‘i. These community health centers are set up similarly to PCMHs in that they use a team approach to healthcare.5 However, even with the multiple community health centers, persistent barriers to care exist on rural island.
At the national level, according to a recent study conducted by Petterson and colleagues (2012), the United States will require almost 52,000 additional primary care physicians by 2025 to accommodate the demand in population healthcare needs. With the passage of the ACA, it is estimated that approximately 34 million people will obtain health insurance coverage, thereby further exacerbating the need for a larger physician workforce.6 In addition, many states, including Hawai‘i, struggle to attract and retain physicians in underserved rural communities that have a higher prevalence of chronic illness. The federal government calculates that approximately 17,000 more practitioners are needed to service the estimated 62 million residents within rural and inner city underserved communities designated by the Health Resource and Services Administration (HRSA).2
Locally, Hawaii has a shortage of 500 practicing, non-military patient-care physicians.2 The physician shortage in Hawai‘i is largely attributed to physician retirement, the aging population, and population growth. It is reported that 41% or 1,200 physicians in Hawai‘i are 55 years or older and nearing retirement age. Therefore, factoring in physician retirement and population growth, Hawai‘i will suffer a net loss of 50 physicians each year.2 Additionally, with the exception of Honolulu County, all counties of Hawai‘i are considered rural communities.7 This creates a more complex challenge for Hawai‘i, as it faces increasing demographic demands for physician recruitment alongside the obstacles of recruiting physicians to a largely rural state. Other factors contributing to recruitment difficulties include compensation and cost of living, workload requirements and after-hour calls, a preference for metropolitan environments, professional isolation, threat of litigation, a lack of community support, and family issues (eg, spousal employment and limited education choices for children).8
This study takes a qualitative approach to better understand how the PCMH model can be advanced in rural Hawai‘i for medically underserved populations. The research team conducted a thorough literature review by searching for approximately 30 key terms through various journal publications. Key terms included words and phrases such as patient centered medical homes, Hawai‘i, rural healthcare, accountable care organizations and patient centered care. A full list of terms is available from the authors by request. This literature review was supplemented by previously collected information from survey focus groups conducted by the Hawai‘i/Pacific Basin Area Health Education Center (AHEC). Finally, the research team conducted interviews with six primary care physicians (PCPs) from rural areas identified through a mixture of convenience and purposeful sampling. The study was approved by the University of Hawai‘i (IRB Reference Number 21886) and Pacific University (IRB Reference Number 202-13). This qualitative research design has the advantage of capturing thoughts and ideas about the most effective methods of PCMH formation and implementation for the rural landscape of Hawai‘i that might not be possible through a more standardized method. It also allowed the researchers to access provider interests in PCMH formation.
To obtain a representative sample of Hawai‘i's spread of full-time equivalent physicians by geographic distribution, three to four primary care providers (PCPs) from each major county including Maui, Hawai‘i, Honolulu, and Kaua‘i were approached. Local experts who were able to identify providers with experience converting to a PCMH also informed the selection of PCPs. Providers were initially contacted by email and asked to complete a phone interview with the researchers that would be recorded and stored on a password-protected computer. To increase the response rate of physician interviewees, Dr. Kelley Withy, the Director of Hawai‘i/Pacific Basin AHEC Program and capstone preceptor, sent an introductory email to potential participants on behalf of the research team. The initial email included information on the research topic, purpose of the study, methods for data collection, time commitment required, the phone interview questions, and a survey monkey link with options for an official phone interview date and time. A follow-up email was sent a week after the initial contact to remind physicians to complete the survey. The researchers, faculty advisors, and sponsoring agency all had access to the raw data. To ensure privacy, however, all personally identifiable information was stored separately from the results of the interviews.
The questions asked during the phone interview can be found in Table 1.
To analyze and interpret the data collected from the recorded phone interviews, the researchers utilized the constant comparison analysis method of qualitative data analysis. Recorded phone interviews were reviewed to identify keywords-in-context. Several major themes were identified from the keywords and through the transcription and review of the recorded interviews and data. Next, the themes were compared to the literature review results to see if any new, corresponding or opposing ideas emerged. Finally, the researchers interpreted all data to determine its application to PCMH formation and implementation in rural Hawai‘i.
Of the 14 physicians contacted, seven physicians responded and a total of six interviews were successfully conducted. Of the six final respondents, three physicians were from the island of Hawai‘i, one was from Maui, and two were from Kaua‘i. To prevent interview bias and protect participant confidentiality, the specialties of the physicians were not disclosed during the interviews.
Four participants reported working in PCMH systems; and of the two that were not, one was currently working toward developing a PCMH and the other had thoughts about creating one. Despite this distinction, the physicians who participated in this study had similar ideas regarding the needs and barriers for PCMH development. Overall, while generally unconcerned with the population density and geographic limitations, many were very concerned with physician shortages and the use of non-physician clinicians to fill the gap. The biggest barrier for those not in PCMHs seemed to be available training, electronic health record (EHR) adoption, and staffing concerns to create functional systems which could care for a population of people. For instance, one participant noted that resources for “…the training and staff time to meet quality measures” created a barrier for PCMH formation. While there are available financial incentives for developing these entities, most practices spend tens of thousands of dollars on EHRs alone.9 That cost, coupled with the increase in costs for enrollment in the National Committee for Quality Assurance (NCQA) or private practice PCMH status, accessing quality reporting, and staff development and training can deter physicians from moving their practices into PCMH status.
The key geographic challenges associated with PCMH formation in rural areas mentioned were provider-to-provider communication and techniques, the usage of rural urgent care clinics amidst the lack of multi-provider clinics, and transportation/resource limitations. Substantial concern was expressed with regards to transportation in island living, especially when specialists are not available for the community or island. One physician observed, “Most [patients] have no way of traveling to [the provider's] location or are traveling anywhere from 50–60 miles. It's inconvenient and expensive, which a large majority of patients can't afford.” The use of urgent care facilities is also a key concern for physicians looking to manage a population. As one physician put it, “…there have popped up urgent care facilities in many rural communicates and people will use those instead of primary care. So that's one aspect that makes it difficult to follow the precepts of PCMH, when you're geographically inconvenienced to your physician.” Further, if visit documentation is not shared, then many services may be duplicated and the most appropriate care may not be performed. Across these identified challenges, respondents recognized that without a network of providers utilizing interoperable communication software, a PCMH model would be inefficient in coordinating care.
The common responses or key terms that arose from interview items pertaining to low-density populations and the barriers to PCMH formation were similar to those that emerged from the question of geographic challenges, with two exceptions. Physicians identified a lack of resources available to adequately staff a PCMH practice and communication concerns with patients as two obstacles that arise from low-density populations. Physicians expressed concerns about finding qualified staff in rural areas that have the skills to properly diagnose, triage and treat patients to the satisfaction of the physician. Administrators and providers need certified staff with critical thinking skills who can be resources to patients as well as assets to the PCMH and physician staff. For example, one physician stated, “…you gotta send the resources more places. You can't have one training group in a big city and send people to one office.” In terms of patient communication obstacles, participants recognized that in many rural communities across Hawai‘i, simple access to cellular phone service or the Internet is difficult at times. Reflecting this concern, one participant said, “…even things as simple as a patient portal are not realistic when people don't have good internet access.”. As patient participation in portal services and patient-to-provider communication are among the quality measures of PCMHs, this issue is not only serious because it is often beyond the influence of the provider, but also because it can affect provider reimbursement.
There were three key barriers presented in response to the question regarding how provider shortages impact PCHM formation: (1) was the higher utilization of non-physician clinicians, (2) physician recruitment barriers, and (3) communication/resource barriers. Although some participants felt that having more non-physician clinicians practicing was a partial solution to addressing the shortage of providers, limited scope of practice was also a concern. The strategy to recruit larger numbers of qualified physicians to work in rural areas in a PCMH model was described as compromised due to the limitations of PCMH reimbursement. Specifically, the physicians interviewed recommended improved reimbursement models for rural PCMH practices for recruiting physicians who are not indigenous to the area and have existing student loan debt. Articulating the need for modified incentives, one physician stated, “…I think people are open to it [PCMH development in an existing practice] but they aren't going to do it of their own accord.” In short, physicians may need to be provided with reasons beyond family and familiarity to seek employment at rural practices. Furthermore, the cost incurred with an increased need for communication between the patient and physicians were also concerns. Improving or finding new and unique ways to communicate with the patient in ways they feel comfortable while being HIPAA compliant was one concern. Another was the availability of typical communication tools, such as telephone or internet, to the patient in rural areas where that type of infrastructure may not be well developed.
Physicians in this study chose to practice at rural sites because of family, quality of life, or the opportunity for a broader scope of practice. The common theme among all rural physicians surveyed was that they enjoyed broadening their scope of work due to the lack of specialists. As one participant observed, “…you get to have a much more rewarding practice with a lot more variety in a rural area.” There was a greater satisfaction in rural medicine for these physicians, because they were not compartmentalized into general medicine and able to work at the top of their license. Family or community ties, whether it be a significant other who wanted to be in a rural area, being raised in the area they practice, or wanting to be involved in the community where they practice, were also commonly cited as a reason for choosing rural locations as the site of their practice. This rationale was linked to quality of life. By creating a foothold in rural communities, physicians felt less burdened, less stressed and more involved with their patients. As one participant noted, “I think we're here because of quality of life.”
A general willingness to work with non-physician providers was vocalized. However, concerns were raised regarding patient preference for providers, communication, pay scale clarifications and medical litigation. Having a non-physician provider on the team takes a great deal of communication and trust, neither of which can be developed overnight. Concern about potential litigation highlighted the fact that physicians may be liable for if non-physician providers move out of their scope of practice. Patients expressing preference of a medical doctor over a nurse practitioner or physician assistant was also of concern, especially in medical home models where physician-patient relationships are so important.
Most physicians interviewed did not use telemedicine due to a lack of resources and absence of a network. Among the exceptions, some physicians reported their practices use remote monitoring equipment for patients. Unfortunately, remote monitoring requires financial and training resources that many practices cannot afford. In general, the researchers did not receive elaborate answers to this question concerning the use of telemedicine, as rural providers lacked the resources to even be familiar with telemedicine. The authors noted a greater use of telemedicine in larger practice or hospital systems, but it still seems to be used sparingly. Funding for equipment and programs seemed to be a barrier to implementation, as well as the lack of familiarity with how to best implement telemedicine in the practice.
Throughout the interviews there was an overall theme of limited resources to develop PCMH practices: Training, recruitment, communication, technology, and financing. With Hawai‘i having one of the highest costs of living in the nation, it is no surprise that limited resources pose a great challenge to providers. The authors' recommendations address this common theme of limited resources, but go beyond the arena of PCMH because the content of interviews indicated additional ideas. The first recommendation is to have an agency in Hawai‘i develop a business model for PCMH development. Physicians noted that they were willing to develop PCMH practices as long as they were not charged with doing it themselves. The second recommendation is to develop a rural track for physicians at the John A. Burns School of Medicine (JABSOM), as well as to develop recruitment via certification programs on neighbor islands to increase the number of certified nursing support staff available for the rural areas. Our third recommendation is to advance telemedicine opportunities in order to develop greater networks of communication among providers and patients. Even though indirect, this can also increase patient access to specialty physicians in rural areas.
Developing an entirely new way of practicing is not easy or straightforward. Most physicians, while focused on clinical practice, must also serve as business managers if they are in smaller private practices. Even those fortunate enough to practice in multi-provider clinics with administrators where they may not have to manage the business matters of the practice, should still be familiar with them. With PCMH standards from both private insurers and NCQA, the complexity of developing a medical home model can potentially overwhelm or deter physicians. Furthermore, given the initial high costs of developing a PCMH, hiring a consulting agency or a new employee to assist with the process is probably not an option for smaller practices. Additionally, Hawai‘i's older physician population specifically could benefit from assistance with implementing this business model. While recent medical school graduates have the advantage of utilizing and studying these technology-based models of healthcare, older physicians may lack the experience or desire to implement these models. Our recommendation is to develop a generalized business plan that physicians can use as a blueprint for developing a PCMH model in their practice.
National organizations such as the American College of Physicians and the American Academy of Family Physicians provide resources to physicians and administrators for developing PCMH models in their practice. Due to the unique circumstances of Hawai‘i's geography and resource limitations, however, having an organization within the state develop a PCMH blueprint that can address these issues can make it more effective. In addition, having trainers on each island available to physicians may make doctors more comfortable implementing the PCMH model. There are some examples of organizations that have offered such models for physicians to utilize. For example, the Icahn School of Medicine at Mount Sinai offers a PCMH resource guide with a comprehensive overview of requirements and standards as well as samples of guidelines for readiness assessments and development in a user-friendly format.10 Physicians are not typically trained in business administration, but by giving providers the resources they need to succeed we can improve the quality and continuity of care in Hawai‘i's rural communities.
A majority of the physicians interviewed noted an early exposure to rural medicine as a reason for being attracted to and continuing to practice in those areas. They also expressed a strong desire for being part of a closely connected community, for greater scope of practice, and for a related sense of a higher quality of life as the positive reasons for practicing in rural areas. The negatives to rural practice included the physician shortage, a lack of qualified physicians and lack of qualified support staff in rural areas throughout Hawai‘i. While many programs encourage practice in rural areas, including loan forgiveness and rural recruitment strategies, there is still a strong sense of under-recruitment of and under-utilization of rural students who have a greater chance of returning to rural areas as professionals. Our recommendation is to expand on the excellent efforts of JABSOM's dean and faculty to recruit rural students and train them on neighbor islands. In a similar vein, participants in this study recommended creation of a rural training track to identify students who are interested in rural practice and give them to opportunity to train in those communities similar to those on the mainland.11 This training track can expose students to mentors in rural areas with a passion for rural medicine, while also introducing students to potential rural work sites.
Hawai‘i's key healthcare stakeholders would also be wise to create more programs on neighbor islands to increase the number of licensed practical nurses and qualified medical assistants trained in PCMH and team based care. Such programs could help to ameliorate concerns regarding the number of qualified nursing support staff available to support the medical home model. One participant voiced the difficulty in finding qualified support staff given the location of training on O‘ahu, “where everything is,” and the need for such staff given that “…the PCMH model is heavy on care management and other activities that a medical assistant or LPN staff would perform.” Though there are multiple schools that offer programs to certify medical assistants (MA) and licensed practical nurses (LPN) in Hawai‘i, the majority of schools that offer those programs are on O‘ahu. Certified MA's and LPN's are necessary to the functionality of PCMH's, as they provide the coordination of care to other providers along with follow-up to the patient to ensure they are getting the care they need. While nursing staff can support medical homes, the expertise and experience of nurses is better served in clinical practice and not in administrative duties. A well-qualified nursing staff can also be more costly to a PCMH than a well-qualified nursing support staff. Having certified, experienced MA's and LPN's creates a higher functioning PCMH. Yet with programs primarily in Honolulu, it is difficult to educate and retain rural residents in rural practices.
As one of the most isolated archipelagos in the world, access to healthcare services is extremely difficult in Hawai‘i. The adoption of telemedicine in practices and hospitals would provide greater access to an array of specialty services, especially those not typically found in rural Hawai‘i. Because many providers currently utilize telemedicine sparingly, greater telemedicine provision offers another path to improving access and the continuity of care. Furthermore, since enhancing access to care and continuity of care are among the determining factors of a successful PCMH, it would be in the best interest of participating rural providers to implement telemedicine in their practices.
Alaska, a useful comparison given its similar barriers to accessible care, has demonstrated what the successful use of telemedicine can look like. Compared to Hawai‘i's current statistics, where 15% of physicians performing telemedicine,12 more than half of providers' contact with patients in Alaska is conducted through telemedicine.13 We recommend Alaska as a model for implementing telemedicine across the Hawaiian Islands, specifically the counties of the Big Island, Kaua‘i, and Maui. However, since adoption of telehealth is currently so low in Hawai‘i, it is important that future attempts to incorporate telemedicine be properly facilitated.
There are four primary limitations to this study. The first is the small sample of providers. It is difficult to ensure that the opinions of a few interviewed providers are representative of providers throughout the islands. A related barrier is that, although the recruited participants from the counties of Maui, Hawai‘i, and Kaua‘i speak to the study's focus on rural health provision, the absence of representatives from the county of Honolulu make the data less generalizable. In addition to the spread of providers, greater variation in the type of primary care providers may have provided more depth and insight. A third limitation of the study is that rather than randomly sampling primary care providers, the researchers only interviewed providers that were associates of the AHEC Director. This convenience sampling approach introduces potential bias. A fourth and final limitation of the study is the potential for bias introduced by the researchers themselves. The researchers were raised in Hawai‘i and are invested in the successful implementation of PCMHs throughout the islands. That said, the researchers attempted to refrain from imposing personal interests and opinions throughout the study.
Future research can help to remedy some of the potential limitations outlined above as well as take the next step in assessing how the intensity of the barriers identified here may vary more specifically for certain locations or by type of primary care provider. For example, a larger, random sample of PCPs in rural Hawai‘i could help to reinforce the findings presented here as well as allow for a more detailed comparison between providers with PCMHs and those considering their implementation. Additionally, future research could follow up on whether and how provider interests in PCMH, EHR adoption, and telehealth usage are changing over time. Lastly, should any interventions be implemented along similar lines to those recommended, it would be possible to assess the utility of the recommendations as strategies to overcoming barriers to the implementation of PCMHs in rural Hawai‘i.
None of the authors identify any conflict of interest
This article was written as a requirement for graduation from Pacific University for both authors. The organization who sponsored this article, the University of Hawai‘i's Area Health Education Center, was involved in the recruitment of the participants in this study.