Raymond Vara

Raymond Vara, newly promoted to the top job at Hawai‘i Pacific Health, is bullish about the future of an industry in the midst of enormous change.

The health-providing nonprofit group (it runs Kapi‘olani Medical Center for Women & Children, Pali Momi Medical Center, Straub Clinic & Hospital, and Wilcox Hospital) has a head start on some of the big changes, he said, and may be a model for others to follow — nationally as well as in this state.

There’s the agreement signed with the Hawaii Medical Service Association, involving reimbursement formulas based more on preventing illness and treatment effectiveness than on volume.

And there’s the program to help independent doctors partner with other professionals to create the team-based approach encouraged in the Affordable Care Act, the health care reform law that goes into full effect in January.

Vara pointed to initial data showing that diabetes patients, for example, have responded well to the early interventions that the move to electronic medical records has enabled.

"We know we’ve improved the health of the population we’ve served," he said.

Vara’s career started with a decade of service in the Army. That included deployment to Cuba with the Medical Service Corps in 1994, at around the time "Camp X-Ray," a detention center that later became known as Guantanamo, was established. He and his wife were both officers, but when the babies began arriving, the couple decided civilian life would be a better family fit.

"I’m 43," he said with a laugh, "but when you have five kids, you kind of age in dog years."

Vara leaves next week to see the eldest of four boys graduate from college and receive his own Medical Service Corps commission. His youngest, Abby, was gravely injured shortly before her third birthday about nine years ago. The near-drowning left her with special needs that Kapi‘olani now fulfills.

"We have Kapi‘olani to thank for giving her back to us," he said. "The silver lining of that is we get to see and experience what care looks like, and use that to impact what we hope care will look like, for not only my family but for all those we touch."

QUESTION: Is the health care industry what you expected when you started your career?

ANSWER: I guess I would say it’s what I hoped it would be.

Q: Oh, really?

A: Yeah, I think so. While the economic challenges of health care are real, and they’ve got to be addressed, today I see more focus on the patient and the patient experience than probably at times in the past. And I think it’s very appropriate that we build a health system that’s not only sustainable but is patient-centered.

So, has it changed? Yeah. But all in all, I think it’s changed for the good.

Q: To what extent were the changes driven from within, as opposed to the Affordable Care Act?

A: Well, I would like to think that the industry has provided leadership in the direction that health care is going. But, in fact, there is a burning platform. Right now health care represents just slightly greater than 17 percent of the gross domestic product in this country, and it’s going to continue to get worse without significant intervention.

But I think if you’re going to be a successful provider of care or even a payer of care through the health plans, you have to have a fundamental belief that higher quality of care is more efficient care. Keeping people healthier, keeping them free of chronic disease, keeping them free of infections, keeping them free of things that come to our patient population without significant and intentional intervention.

If you fundamentally believe that, then you fundamentally believe that the movement that we’ve seen over the last several years in health care is the right direction and the right course.

Q: How do you think Hawaii is positioned to adapt to health care reform? Or is there less room for improvement here, so we won’t feel a difference?

A: I think the fact is that when it comes to cost per beneficiary served, or cost of commercial insurance premiums, in Hawaii we’re in a much better place, at least from a sustainability standpoint, than other states. Does that represent the fact that our opportunity to drive economic change through the system is less? Well, I suspect it is.

And so we do have some inherent efficiencies. We know that we’ve got a lower number of uninsured because of the Prepaid Health Care Act. …Yes, we are better off in that regard than other states, so it does diminish the opportunity, from that standpoint.

That being said, I do think we have opportunity. Frankly, because of where we’re at relative to the rest of the nation and the work that’s already been done here, we have a tremendous opportunity to be on the leading edge and provide leadership in terms of the reform effort. …

If we’re proactive, which certainly Hawai’i Pacific Health has been, and the other providers of the state, I think we have an opportunity to lead the country in terms of how to truly create a sustainable health care environment.

Q: Do you share the concern by some that compensating providers enough to keep them in the profession will be a challenge?

A: Well, I think that’s the fundamental challenge on a national basis. How do you make sure that the dollars that are currently funding the broader system go to all the places, whether it’s the provider group, whether it’s the health plans, or beginning to bend the cost curve for the employers and employer groups? I think we have to make sure that the flow of the health care economics matches the intent.

Right now our process functions just as it was designed to function. We are paid on volume-based activity. (If) we see more visits, we see more admissions, we do more MRIs, more CT scans, (then) we generate revenue and the dollars exchange hands based on that.

I think the beauty of our contract with HMSA, which is going to start January 2014, is it really begins to align those incentives. It allows us to move from that volume-based environment to a value-based environment.

When we see decreases in the medical cost trend within our population of patients, we share that, and everybody benefits. …

Q: What will be the effect on the existing provider shortage in certain areas?

A: I think the shortage of providers, the economics, the financing of health care is one element of the shortage we experience. The other is the model.

Right now, we don’t have a model of care that probably puts the physician practice … to use in the most efficient way.

We should be able to have a system and a process that allows physicians to practice at the top of their license. We should be able to leverage technology to be more efficient. If you don’t need to go in for an office visit in order to manage your health care, you should be able to do that — whether it’s our electronic medical record portal on your home computer, whether it’s on your cellphone, or whether it’s through seeing a "physician extender," like a nurse practitioner or a physician assistant, as part of that true team-care approach.

What that does is that truly lets the physicians in all the various specialties only see the patients that, frankly, really need to see a physician with that training and that skill set.

Q: How do you answer the criticism that "practicing at the top of their license" means some professions will be working beyond their capabilities?

A: I think that it’s incumbent on us in the health care field to educate on how in fact that team-care approach can be better for the patient. … It will be more efficient for their time as well. It can give them the time and the access to the individual providers that they may or may not get from a physician. …

It’s the benefit of the time and the ability to have that discussion to truly address the questions you have, from someone who’s capable and competent to answer those questions.

Q: So, who needs to be educated here? The community?

A: I think it’s the patient population but it’s also within the provider community, and to some degree it’s even with the payers themselves — the health plans and others. …

We’ve been working not only with our employed physicians but our independent physicians. … It’s really about partnering with them to develop these models of care. It’s like, "How do we help you practice the kind of medicine on behalf of your patients that you went into medicine to do? How do we make it easier to care for your patients in the best way you know how?"

Q: What is this partnering, specifically? Workshops? Conferences?

A: A little bit of all of that. We have continuing education that takes place at each of our facilities. …

The greatest fear of a physician in private practice is losing that independence. And yet, most informed physicians today recognize that in the future, they’re going to have to be part of something bigger than just themselves. … I think there are many ways to do it, as long as you commit to putting the patient first. …

Q: Shifting to the present: How has Pali Momi adapted to the ongoing shortage of emergency care on the west side?

A: All of our emergency rooms are busy. … We’ve put different models of care into place. We use a team triage system at Pali Momi. One of the first people you see when you show up at the Pali Momi emergency room is a physician who determines whether you need lab work; they send you to get that now while you are waiting. … It’s really using multiple layers of physicians within the emergency room experience to help streamline the length of stay.

We’ve expanded space in the facility. What used to be the physicians’ dining room is now treatment areas.

Q: On a personal level, has your experience with your daughter’s care affected your job?

A: I would suggest that it makes me better at my day job, having lived what with we’ve lived with and experiencing what we’ve experienced. Being an advocate for Abby, I think, has a residual effect in terms of being an advocate for all of our patients. I would be hypocritical if I didn’t expect that we’d deliver the same kind of care for all of our patients at all of our facilities that I would expect for her.