Among the most underserved people in Hawaii are the aged, blind and disabled with low or no income. Historically, the Department of Human Services has reimbursed health providers to care for these patients on a direct, fee-for-service basis, albeit at a very low rate. In an effort to control costs, in recent years DHS has issued requests for proposals from organizations that could manage and administer this benefit. Although local entities such as AlohaCare placed bids, many were surprised to learn that contracts were awarded to Ohana and Evercare, two entities based on the mainland.

As it stands today, Ohana and Evercare receive a fixed per-member, per-month fee from DHS to manage the health needs of this patient population according to agreed parameters. They, in turn, attempt to recruit and credential health providers. Once credentialed, providers then care for patients with the relevant coverage and receive reimbursement for services rendered.

At least, that is how it is supposed to work.

The argument in favor of setting it up this way is that DHS can now rely on known, fixed costs for each month a patient is on the Ohana or Evercare roster. These two contractors are meant to be skilled in managing care and hence optimize outcomes by helping to ensure that patients receive necessary services. They are also charged with managing utilization. Their margin is the difference between their fixed income from DHS and what they pay out for health services and products.

Many primary care providers do not accept Ohana or Evercare patients for several reasons. These cases tend to be extremely complicated and labor intensive. The majority have multiple medical problems and historically have had poorly coordinated care often through no fault of their own. Many are victims of physical abuse and sexual abuse. Many have engaged in substance abuse, and a very large proportion suffer from associated mental illness. They have a high rate of obesity and diabetes, and cancers tend to be found late. Most have difficulty with transportation and cannot always make their scheduled appointments. Noncompliance with treatment plans is also a frequent problem.

In addition, the process to obtain approval for reasonable and necessary diagnostics is time-intensive and often ultimately unsuccessful. Even if approval is secured for needed specialty care, it can be difficult to find a suitable specialist willing to treat this population. In the end there is a tremendous burden upon primary care providers and their staff at every level. Many become overwhelmed by the challenge of serving this medically fragile population.

Still, there are providers who prefer to care for the most underserved because that’s where they can make the biggest difference. Others providers simply wish to shoulder their fair share of the burden and honor their Hippocratic oath. Hawaii’s Community Health Centers are doing a stellar job of taking care of these patients and continue to face tremendous demand without adequate resources.

In addition to these challenges, providers are finding increasing problems getting paid at all. Colleagues say there is a consistent set of responses from payers, such as "systems problems," "still processing" and "making progress on your claim." However, none of those communications readily translates into reimbursement. For this reason, in addition to those already mentioned, some providers have no choice but to decline to offer further care under these payers. The system is bracing itself for another blow. It’s possible the state will announce a further cut in funding next week.

Rio Banner, M.D., has a sterling reputation in the community for service to some of the most challenged populations. He has worked as medical director of the Waianae Coast Comprehensive Health Center. He was a mentor to residents in the Preventive Medicine Residency Program at UH and was a co-founder of AlohaCare. After serving there for many years, he recently took the reins as medical director of Ohana. If anyone can fix the problem, it is Dr. Banner.

According to Banner, Ohana is working to move away from long-term care in hospitals. "Our goal," he says, is "patient and community satisfaction in the home." Then again, sometimes the best intentions and abilities of leadership are still not enough to overcome a dysfunctional system. The suffering of the underserved in the state of Hawaii is profound. A great deal of care is needed, and resources are few. We must find a better way to support front-line providers to offer health care for those who need it most.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.