Column: How to reverse loss of Hawaii’s primary care doctors

At the Hawaii Health Workforce Summit conference on Sept. 7, we learned that Hawaii is now short more than 800 full-time doctors, and we lost another 108 in the last year. A quarter of those who remain are 65 or older. Many of the doctors quitting practice or moving to the mainland blame HMSA’s payment transformation for failing to increase primary care pay enough to cover increased staffing and practice overhead required by the payment model.

HMSA’s payment transformation relies on pay-for-quality incentives and adjustments for severity of illness that depend on detailed documentation and data reporting — and the model attempts to reward doctors who provide this documentation and reduces payment for those who don’t, creating winners and losers.

According to a Hawaii Medical Association survey of primary care doctors, less than a quarter are happy with the model and doing better financially, and around 60% say their practices are doing worse financially, many to the point that they cannot keep their doors open much longer.

Doctors new to practice are faring worse than those with large, established practices. The complexity of the new payment model makes cash flow and practice expenses impossible to predict, so doctors coming out of training are unwilling to go into independent practice, and far more are leaving Hawaii for the mainland than the reverse.

If HMSA wants to continue with payment transformation, there are only two ways it can avoid driving large numbers of primary care doctors out. It must either increase primary care pay enough to cover the staffing needed for the payment model, or it must reduce administrative demands of the model enough so that primary care practice here is viable again, or both.

Reforms should return control of care coordination to primary care practices. Health plans should be in a supportive role, not managers with metrics telling primary care doctors how to spend their time. Assure primary care payment is adequate and in proportion to the central role primary care should play in health care. Make payment predictable and minimize administrative burdens, as HMSA used to do before payment transformation.

Some suggestions:

1. Eliminate pay-for-performance. Primary care doctors are already motivated to provide quality care for patients without being manipulated with financial incentives. If primary care pay is adequate and in proportion to the training required and value of primary care, then no further financial incentives and disincentives are needed. Reining in inappropriate care is best done through peer review and quality improvement projects, not financial incentives and disincentives.

2. Disconnect payment from the details of documentation. Pay primary care physicians for their time and expertise, not “pay-for-documentation.” This could be accomplished with either capitation without pay-for-performance or a fee-for-service system based on the time associated with each procedure.

3. Give primary care physicians control of their time. Payment should include time for documentation and care coordination, not just face-to-face time.

4. Refocus information technology on patient care support and quality improvement, not micromanagement of clinical decisions with financial incentives to do what doctors are already motivated to do.

5. Markedly reduce prior authorizations (PAs). HMSA should take back control of PAs from its pharmacy benefits manager and mainland contractors, and use a panel of local physicians to review all PAs, limiting them to drugs and procedures where there is a demonstrated, substantial risk of inappropriate use.

These suggestions would cost less to administer for both HMSA and primary care practices compared to the current version of payment transformation. They would restore the joy of practicing primary care, and assure the financial viability of primary care practice in Hawaii. We could then retain all the doctors coming out of medical school whose first choice would be to practice primary care here, plus attract more from the mainland who want to practice in an environment supportive of primary care.

Stephen Kemble, M.D., is a psychiatrist and former Hawaii Health Authority member.