Multiple forces — some permanent facts of life in the islands, others temporary — are now compounding their effects to shrink the supply of doctors in Hawaii, now at its lowest ebb in four years. Efforts to counter this are underway but must accelerate if the state is to head off a severe crisis of care, especially on the neighbor islands.

The latest survey from the Hawaii/Pacific Basin Area Health Education Center indicates a current shortfall of 830 doctors statewide. The center, based at the University of Hawaii John A. Burns School of Medicine, estimated that the state’s aging population needs at least 3,481 active physicians but has only 2,819.

This is anything but a new problem, but it’s plainly getting worse. Many of Hawaii’s doctors are baby boomers who are retiring en masse, at the same time all the other boomers and their elders are needing more care.

The current campaign to reorder the health-care economic landscape — dubbed “payment transformation” by Hawaii Medical Services Association, the state’s largest health insurer — is surely one additional factor that’s pushing more doctors toward the door.

But there are many more, unfortunately. Those in the industry make numerous observations about the job market in medicine:

>> One reason there are many struggling with payment transformation is that a disproportionate number of physicians in Hawaii are still private, individual practitioners. They say they need more predictability about income than the HMSA system provides.

One critic of the system, Dr. Stephen Kemble, said that this started with the insurer, which controls the largest share of medical coverage. HMSA’s original “fee for service” payment system standardized fees and made them predictable, which enabled Hawaii doctors to project costs and start an individual practice.

Now predictability has been lost, he said, meaning that especially newly graduated doctors gravitate to the mainland where more of the marketplace has converted to group practices. Young doctors now prefer being employees but find fewer group opportunities here, he said.

>> There is the cost-of-living issue that affects everyone, including the cost of housing and the prospect of paying for private school for children. This is weighed against the sizable college-loan debts many new doctors carry.

>> Hawaii health-care institutions compete for recruits across the mainland, making it tough to fill slots — especially as some prospects are deterred by Hawaii’s geographic isolation and distance from their extended families.

Of course, Hawaii has begun the transition to group practice. But its health-care institutions are recognizing that adaptation to new payment and cost-management models are deterring many doctors that the state needs to keep in place, if at all possible.

HMSA and other Hawaii health-care institutions now recognize that the change is hard on doctors and have done outreach. Clearly, they do own some of the problem and must offer further help to physicians in making adjustments.

Some health-care centers are meeting to share ideas about more effective recruitment, an encouraging sign of collaboration. But there are already critical specialization shortages, especially on the neighbor islands. General practitioners increasingly must be supported in creating partnerships through telemedicine and conferencing to bridge the gaps.

And there must be continued exploration of ways in which nonphysician providers can extend the doctor’s reach to patients. One such strategy is identified in “Healthy Hawaii 2020: A Community Health Plan,” a blueprint issued by the state Health Department following a community health needs assessment by the Healthcare Association of Hawaii.

It recommends that doctors form a team including pharmacists and others to work with patients on managing their chronic diseases. This more collaborative approach is applauded by HAH, said its president and CEO, Hilton Raethel.

Of course, HAH also recently issued a report detailing how all of those non-physician health professions also are encountering similar shortages that must be overcome as well. Raethel said the association is continuing to work with the state Department of Education on expanding its “health academy” approach to promote the health-care professions among students from a young age.

Another task is to enable credentialing for more of these support professions in Hawaii. Some high-need professions, including physical therapy, need programs to be established locally, and the University of Hawaii has shown some interest in starting one. Lawmakers next session must take a hard look at ways to address all such crucial workforce needs.

Hawaii has a reputation for being one of the healthiest states in the nation. If the state seeks to maintain that status, the critical gap that has opened across its health-care professions is a complex problem that will take a concerted effort by public and private partners to overcome.