Rich Bettini never envisioned a professional career in Hawaii. But one rainy day while he visited friends, an opening in Waianae caught his eye and the friends advised him it might be pleasant to check out a job some place where it likely was sunny.

Bettini fell in love with more than the weather. The chief executive officer of the Waianae Coast Comprehensive Health Center for the last 20 years splits his time between homes in Makaha and Honolulu.

The center itself, including a brand new clinic facility, is nestled into a Waianae hillside. But the work of running a federally qualified dispenser of care primarily to rural and lower-income communities involves a lot of face time with government officials in town.

His focus is clearly on the ever-expanding center, which once had a staff of 50 but now employs 600 people. Construction of a new emergency room is set to start early next year.

With an academic background in business and a master’s degree in public health from the University of California-Berkeley, he sees job development as part of the holistic health goal. The unemployed and the homeless end up with complex problems, none of which support getting to the doctor for regular preventive health checks, he said.

His name popped up in the news earlier in the summer when talks for a contract with the Hawaii Medical Service Association hit a snag, partly over how the center structured its medical "home" care delivery. Bettini is convinced that hurdle can still be overcome.

Bettini is married and recently indulged his passion for travel with a globe-circling vacation. He batted away a question about age, quipping that he didn’t want competitors sending him to the "elephant graveyard."

But he’s eager to showcase every inch of the center, including offices where a largely homegrown staff was groomed in on-site programs for myriad jobs, from developing the software that now tracks health care results, to positions in the health fields themselves.

"We’ve trained 1,800 people over 12 years in entry-level jobs, home health aides, nurse aides," he said. "Having a job, it makes a huge difference for paying the groceries."

QUESTION: What is the nature of the problem with an HMSA plan for your Medicaid users?

ANSWER: We don’t see it as a problem. I think the issue with HMSA was not about money or anything. The issue with them was what is the model going forward with health reform. …

Everybody is looking at how do you cut costs in health care. … I would say a quarter of health care costs could be contained if we address the reasons for preventable costs. And so much of that is keeping people out of hospitals and emergency rooms and giving them access to primary care.

So we mapped out a plan. It calls for moving a lot of the technology and care coordination to the community level, so we don’t have four health plans sending their care coordinators here, and four technology systems, (where) a patient comes in and we try to fit them in the slot of an insurance company. Instead, what we’re trying to do is create one system, and if you’re an insurance company we’ll work with you, if you work with our system.

So we have three health plans that agree, and with HMSA it took over a year, and we will get there. But up to this point we haven’t reached an agreement on how to share data and how to use our care coordinators at the community level.

And I can understand: They’re a very successful organization, and it’s hard for big organizations to change to accommodate little organizations, you know.

Q: So you’re saying your plan is tailor-made for your …

A: For our patients. Our patients are very complex. We have 200,000 clinical visits a year. This is our main site, but we’re the safety-net provider for all of West Oahu. We have clinics in the Fil-Com Center, Kapolei, Nanakuli. And two-thirds of our patients come below poverty level. …

You need to treat people in the community they’re from and provide an integrated model that includes behavioral health in the same room, integrate dental, have outreach workers that they know and trust that get them to come in for primary care. … Reducing low-acuity ER visits, when people go to the ER but they really don’t need to. Hospital readmissions, where maybe people come out of the hospital with something newly diagnosed and they don’t have the support system or a family doctor.

Q: They get sick again?

A: They go right back in. So there are so many cost drivers. Now, with our patients we have so many patients that have both chronic disease or precursors to chronic disease. So obesity,

dietary issues. That combined with huge stressors at home: no job, no house. And also, quite a few people diagnosed with depression or substance abuse. …

We need insurance companies. They do some good things. They process claims, they communicate claims and they help us form a network. But some of the stuff they do we can do ourselves, and get better results. So the contracts we have with other plans, we sit with them, we come up with seven financial performance metrics, reduce inappropriate hospital ER visits, and let’s score us on continuous quality improvement. …

And if we create margins in the risk pool, the pot of money, part of that comes back to the community to support job training and economic development programs and things like that.

Q: When you say part of that comes back to the community, what do you mean?

A: One of the big changes in health care is to align incentives to address preventable costs. … So what we say to the plan is, at the end of the year, let’s do a 360 evaluation: what you did to contribute to preventable costs and what we did. And then whatever’s left in the pot, it goes back to the health center, or it gets shared with the plan, rather than all of it going to the plan.

Q: So this is how all the stakeholders share in the savings?

A: Yeah. The idea is to align everybody around a common mission, and that is to improve quality. But also, there’s a hunk of money that’s wasted in health care. Well, you have to align the whole system to address it, and the best way to do that is to incentivize people.

Let me give you an example. … We have a list of the number of visits our patients have had to emergency rooms when they probably didn’t need to go to the emergency room, and most of them were in Kapolei, and not at our Kapolei clinic in that area, rather than Waianae. So why is that? Because we’re open 24 hours here; when people come to our ER at night, we just get paid a regular flat fee, we don’t get an ER fee. …

In Kapolei, we close at 5, 6, like that. So people have nowhere to go, so they go to hospital-based ERs, which correlates with much higher costs per visit.

So we started toying with the idea: Can we start opening at night in Kapolei? … How can we afford it?

If we’re focused on addressing preventable costs and keeping people out of the ER, and the incentive is such that we "gain share" at the end, you throw that revenue potential into the model, and it makes sense to open at night and cut down on inappropriate ER visits.

Q: So you would add some hours, and hopefully revenue would cover that?

A: Yeah. … We’ve got a very effective board of directors. They want to see a business plan that we’re going to break even. Well if I can plug a little revenue in from gain-share, they’re happy. I make the number. And we address preventable costs.

We’re going through a period of huge changes in health care, and everybody’s looking at what role they’ll play, but I think the bottom line is we need to address preventable costs, work that out of the system and come up with ways to incentivize that for everybody in the network.

Q: So is the problem with HMSA coming up with the right formula?

A: You know, we got 85 percent of the way down the path with them; we’ve got just a little ways to go, and I think all we’re trying to have them do is match what other plans have offered.

The interesting thing with what happened is the federal government kind of stepped in and said, "You can’t turn anyone away: you’re a community health center," which is true.

Q: How do you deal with that problem?

A: An interim agreement has been hammered out where we’ll get a certain level of payment, but it will be, in aggregate dollars, I would estimate 30 percent less from what we would get from other plans. …

If we’re going to continue to … offer quality care, we have to look at new models for how we can sustain what we do.

Q: How would you describe your approach to a patient health care "home"?

A: One of the ways we’re addressing continuous quality improvement in the health care home is to address preventive aspects of diabetes, and do it with multiple agencies in the community. It might mean that our medical home builds bike trails. It might mean all kinds of things, but in a community like ours, that’s a proficiency.

We look at engaging community, we look at workforce, we look at culture and we look at something called "care enabling," which is breaking down access barriers to care … It may be transportation, it may be translation. It may be having understanding that we have to offer additional services to people who don’t read and write, or people who don’t have homes. …

We’re looking for health-plan partners that recognize that risk adjustment and different kinds of outreach have to occur if incentives are to be correctly aligned. We’ve been working on this model for six years, and other plans — even for-profit plans — have said this is really good, maybe not for everyone, but for communities like Waimanalo, Waianae …

Q: What’s your take on the health care reform process we’re grappling with now?

A: I think we do have to experiment. The way we see it is, if we stay focused on addressing preventable costs in complex and low-income patients — and everyone at this health center knows that’s our job, so we move as a group — there will always be a place for us. Because if we were to go away, it’s going to cost somebody more money.