Hawaii is facing a healthcare workforce crisis—one that’s deepening existing disparities and impacting the health of the state’s inhabitants.
“Hawaii has historically been a poster child for diversity, and we are known for our healthy lifestyle,” said Elizabeth Ignacio, MD.
Elizabeth Ignacio, MD
Hawaii is one of the most diverse states in the United States, with a multilingual and multicultural population including Japanese, Chinese, Korean, native Hawaiian, Pacific Islander and Filipino residents. But as Dr. Ignacio points out, despite the assumptions of Hawaii’s healthiness, underserved populations of the Aloha State experience many of the same disparities facing underrepresented minority communities in the rest of the country.
The Hawaiian health crisis
According to the Office of Minority Health in the U.S. Department of Health and Human Services, data indicate that rates of smoking, alcohol consumption and obesity are higher in Native Hawaiian and Pacific Islander communities. These problems are compounded by a lack of adequate access to cancer prevention and control programs in those communities.1 Diabetes is also a large concern—Hawaiian underrepresented minorities (URMs) are 2.5 times more likely to receive a diagnosis than white populations, and data indicate that 39% of the population has uncontrolled diabetes. Finally, compared with white populations, Asian American URMs in Hawaii have nearly twice the infant mortality rate, are four times more likely to suffer from a stroke and are three times more likely to be obese compared with the overall Asian American population.1,2
The factors leading to these disparities are the same as those in many rural communities or underserved ZIP codes: cost of living, food scarcity, housing and accessible health care. Due to the provider shortage, access to care is a key concern for Hawaii.
“When we talk about Hawaii, we are talking about the problems facing a lot of areas in the United States,” Dr. Ignacio said. “The state is touted as very healthy, with a focus on the outdoors and employer-required insurance programs. But one of the things that we’ve been failing in is our provider numbers. Although our patients are diverse and many are physically fit, we’re not meeting the challenge of how many providers exist in our state.”
This deficit has a direct impact on access to care. Since the start of the COVID-19 pandemic, Hawaii’s patients have faced escalating delays in medical care and are increasingly required to travel between islands for specialty or even general care.6 This is costly and sometimes impossible for patients who cannot afford the travel or cannot get time off of work or arrange childcare during work hours.
Access to IR services in particular is also limited, especially for patients outside of Oahu, according to Roger Tomihama, MD, who studied at the John A. Burns School of Medicine at the University of Hawaii at Manoa.
“Many hospitals on these ‘outer islands’ really function as basic community hospitals with limited subspecialty care,” he said. “Similar to many remote locations in the continental U.S., these patients have to travel for hours to access a tertiary care facility to receive IR services. However, what is different is that patients in the outer islands of Hawaii have to fly into and out of Oahu to access these services, which can be challenging immediately after having an procedure.”
The physician shortage
Despite being billed as a “paradise,” the state has a critical shortage of practicing physicians. A 2021 analysis found that Hawaii County had the third highest shortage of primary healthcare professionals in the nation, and a 2022 report found that 75% of Hawaii’s rural hospitals were at risk of closure.3,4 Many states like Hawaii suffer from an ongoing physician shortage, and the level of subspecialty shortage in fields such as IR remains unclear and likely underreported.
The lack of IR training programs in Hawaii likely contributes to this shortage, Dr. Tomihama says. After graduating from the University of Hawaii, he had to leave the state for his radiology residency and now practices in the continental U.S.
“The University of Hawaii has residency training programs in many general specialties, and even many subspecialties,” he said. “However, there are no diagnostic or IR training programs in Hawaii. Because of this, many graduates from the University of Hawaii have to leave the islands to pursue radiology training. This drain of local student talent likely contributes to the reduced number of practicing IRs in Hawaii, especially if these individuals end up staying and practicing in another state.”
According to Dr. Ignacio, the difficulties of practicing in Hawaii also make it hard to retain physicians in the state.
“Very often, if prospective physician interviewees are asked why they want to practice in Hawaii, they will say that they traveled here on vacation and love the outdoors and hiking and surfing,” Dr. Ignacio said. “That’s an honest answer, but those passions won’t necessarily sustain you when you see how difficult it is to practice here.”
One challenge is that many physicians in Hawaii are paid significantly less than their mainland counterparts, Dr. Tomihama says.
“Given this challenge, many IRs are forced to make up the revenue by reading diagnostic radiology films,” he said. “This compensatory revenue work requirement sometimes can preclude IRs from focusing all their time and energy on some of the non-compensated aspects of IR (such as clinic, practice building, etc.).”
Like many rural areas, the cost of living and housing is also a substantial barrier to recruitment. According to World Population Review rankings, the cost of living in Hawaii is almost twice the national average, making it the most expensive state in the United States to live in. Groceries cost almost 50% more than the national average due to shipping requirements, and the state has a well-documented housing crisis.5 For incoming physicians, these barriers, coupled with lower salaries and reimbursement rates, make it both difficult and undesirable to establish a practice in Hawaii.
“It can be very disheartening and discouraging to practice here as a young physician, struggling with enormous student loans, barely able to afford your workspace and staff, and so far from family with no connection to the community,” Dr. Ignacio said. “So many will leave after 2 years here.”
Those cultural connections and willingness to gain cultural competency is crucial to practicing in an area like Hawaii—and that connection is what drives Dr. Ignacio’s commitment to the state’s residents. “It is the warmth and kindness of the small and rural communities that has easily drawn me in. I know that the spirit of Aloha is real. People want to get to know you, to look you in the eye and know how your day is going, even if you’re just standing in line at Walmart. It’s called talk-story, and that ability to genuinely connect is beautiful—it’s a unifier of the multiethnic culture of Hawaii.”
Is telehealth the answer to provider access?
In July 2022, Community First Hawaii published Access to Care,6 a Centers for Disease Control–funded review of the state health disparities developed in partnership with the county of Hawaii, the state department of health, the Hawaii Medical Association, and the largest insurance and health providers in the state. The review surveyed both patients and providers with the aim of closing these disparities and improving access to care. According to the findings, the state must address the provider shortage and adapt practices to reflect the values and identities of local populations.6
One often-cited solution is expanding access to telehealth services. But according to Dr. Ignacio, telehealth can be a blessing for some and a nightmare for others.
Telehealth became increasingly popular during COVID, as it allowed physicians to see more patients a day and negated many of the logistical barriers to care. However, the Access to Care survey found that many Hawaii residents are hesitant or unable to use telehealth. A sizeable number of residents don’t have reliable internet access or smart devices, or they are unable to afford the data bill required for such a phone.6
“We’re making such great technological advances, but we’re also widening the gap,” Dr. Ignacio said. “Studies show that even as we make technological advances, we’re also making it harder for people from socioeconomically challenged backgrounds and underrepresented communities to gain access.”
In addition to logistical issues, many patients said they felt the technology causes a lack of personal interaction and connection, and this was especially true for older patients. Patients also said they don’t trust physicians to diagnose them through a phone and may feel uncomfortable answering personal questions from someone who doesn’t understand the realities of where they live, Dr. Ignacio says.
“Many of our patients, especially those who are native Hawaiian, Pacific Islander or Filipino, don’t trust the telehealth platform,” Dr. Ignacio says. “The doctor may not understand their language, or they feel hesitant and/or embarrassed having to go to a health center to access a terminal to talk to a provider 2 hours away.” Though technology is the bread and butter of IR, it also must be thought through carefully, she says.
“Technology is an amazing tool. But we must make sure that as we advance, we’re not outpacing our ability to connect with patients.”
Connecting communities
Though telehealth can play a role in improving disparities, everyone agrees: the state needs more providers, especially ones who understand the local populations.
The Access to Care report6 proposed solutions, such as reaching out to engage local students at earlier stages to promote and encourage their pursuit of medicine. Local home-grown talent is a real win for all small and rural practice, and pipeline initiatives are vital to this end. The study also recommended targeting bilingual individuals and those from underrepresented racial and ethnic groups, as well as offering free or reduced tuition to those who commit to residency within the state.6
“I’m Filipino and sometimes that makes it easier to connect,” Dr. Ignacio says. “Patients in Hawaii may feel more comfortable being cared for by a physician who looks like them and understands their cultural perspective.”
She reiterates the need to help young physicians, especially those who can speak the local languages and understand the cultural sensitivities of patients, see the advantage of practicing in their home region.
“We’ve seen in California and Texas that, if you understand the language and community of your patients, you will be more invested in the community and have more engaged patients.”
In addition, physicians should get creative and embrace different practice models, Dr. Ignacio says.
After working in a regular practice for several years, Dr. Ignacio chose to open her own practice, which would allow her to work all over the state.
“The traveling IR isn’t a new idea,” she said, “but it’s a successful one.” In addition to gaining control over her own schedule, Dr. Ignacio says part of the value of her model is that she can travel between islands, cover practices when they are shorthanded and support patient access directly to IR specialists.
“A rotating contract IR physician of a small and rural practice can make an immense difference and connect with a whole new patient population if you are flexible, and you can showcase the positive downstream impact of IR therapies.”
Changing policy
Recruitment and retention efforts must also come from the top down, Dr. Ignacio says, which requires changing policy and gaining advocates at every level.
“There is nothing ground-breaking or shocking in the Access to Care report,” Dr. Ignacio says. “But look at everyone who is involved. The report is important not only because it affirms what we already know, but because it is concrete patient evidence developed in collaboration with the stakeholders who have the ability to change things. Projects like this demonstrate the strength of collaborators who are listening and willing to help.”
In recent months, several large sources of funding have been earmarked for identifying ways to improve health disparities and workforce shortages. In Oct. 2022, the University of Hawaii received nearly $1 million to launch a new rural health policy research program,7 and Congress designated $23 million for 14 community health centers throughout the state.8
“We have to be creative, leverage the funding and resources,” Dr. Ignacio said. “Unless we support small and rural practices, the development of reimbursement reform and sustainable practice models, states like Hawaii won’t be able to recruit and retain physicians.”
Change is on the horizon, according to Dr. Ignacio. Societies like SIR have become increasingly aware of and supportive of health care disparities and workforce shortages and have efforts underway to improve access, reimbursement rates and support the next generation of culturally competent physicians. It’s a long road, but with awareness and buy-in, Dr. Ignacio believes that patients will see the benefits in time.
References
- U.S. Dept of Health and Human Services. Minority population profiles, Native Hawaiians/Pacific Islanders. minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=65.
- Hawai’i Pacific University. Ways to eliminate Hawaiian health disparities: Improving health equity. bit.ly/3Vwb5ZG.
- U.S. Dept of Health and Human Services. Health Resources and Services Division. HPSA Find tool. data.hrsa.gov/tools/shortage-area/hpsa-find.
- Tucker N. 631 Rural hospitals at risk of closure by state. Becker’s Hospital Review. Nov. 8, 2022. beckershospitalreview.com/finance/631-rural-hospitals-at-risk-of-closure-by-state.html.
- World Population Review. Cost of living index by state. 2022. worldpopulationreview.com/state-rankings/cost-of-living-index-by-state.
- Access to Care, July 2022 Report. drive.google.com/file/d/1E4jhUY7UME7P_ht-c3DceN0zHyJGTsaI/view.
- Improving rural healthcare goal of new UH research and policy center. University of Hawai’i News. Nov. 10, 2022. hawaii.edu/news/2022/11/10/uh-rural-health-research-center.
- Peterkin, O. Hawaii health centers to receive more than $25M in federal aid. Pacific Business News. March 15, 2022. bizjournals.com/pacific/news/2022/03/15/hawaii-health-centers-receive-23-million.html.
