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HomeMy WebLinkAboutMIN HSSSC 2022/04/05 2020-2022 Committee on Human Services and Social Services 16th Session Hawaii County Building 25 Aupuni Street Hilo, Hawaii April 5, 2022 CALL TO The regular meeting of the Committee on Human Services and Social Services ORDER: was called to order 1:00 p.m. in the Council Chambers, Hilo, by Ms. Susan L. K. Lee Loy, Chair. ROLL CALL: Present: Ms. Susan L. K. Lee Loy, Chair Ms. Ashley L. Kierkiewicz, Vice Chair Ms. Maile Medeiros David, Member Mr. Holeka Goro Inaba, Member Mr. Matt Kaneali`i-Kleinfelder, Member (came in later) Ms. Heather L. Kimball, Member Mr. Herbert M. "Tim" Richards HI, Member (came in later) Ms. Rebecca Villegas, Member Absent& Excused: Mr. Aaron S. Y. Chung, Member(came in later) STATEMENTS The Chair directed the Committee to proceed to the next order of business, FROM THE Statements from the Public on Agenda Items. PUBLIC ON AGENDA ITEMS: (There were none.) CHR. LEE LOY: Mr. Clerk, Communications,please. COMMUNI- The Chair directed the Committee to proceed to the next order of business, CATIONS: Communications. Comm. 692: REQUESTS A PRESENTATION BY HAWAII STATE RURAL HEALTH ASSOCIATION REGARDING ACCESS TO HEALTHCARE ON HAWAII ISLAND From Council Chair Maile M. David, dated March 16, 2022. Motion to Close File: Ms. David moved to close file on Comms. 692. Seconded by Mr. Inaba. CHR. LEE LOY: Ms. David, this is your communication. MS. DAVID: Thank you very much. HSSSC-16 April 5,2022 CHR. LEE LOY: Go ahead. MS. DAVID: Yes, mahalo. And today I'm very privileged to recognize and welcome Randy Kurohara, Executive Director of Community First Hawaii, and Lisa Rantz, who is the President of Hawaii State Rural Health Association and the Executive Director Hilo Medical Center Foundation. Would you two please come up to the table? (Note: At this time, Mr. Randy Kurohara, Executive Director of Community First Hawaii; and Ms. Lisa Rantz, President of the Hawaii State Rural Health Association, came forward to address the members of the Committee.) MS. DAVID: I just also want to say thank you to Vice Chair Chung, who actuallyI reached out to him, and he was totally willing to have this presentation, but then I accommodated him and did the communication, and I'm happy to do this because what you are going to be presenting is an island-wide issue, and so I welcome you folks to the Council and introduce yourselves, and you can go ahead. MR. KUROHARA: First off, thanks for having us. It's been awhile since I've been in this chamber, but I like it. Anyhow, yeah, thanks so much. I'm Randy Kurohara, Executive Director for Community First. I've been in this role for the past maybe 13 months. MS. RANTZ: And aloha. Good afternoon. My name is Lisa Rantz, and I have the privilege of working with Randy on this very important project. Pulling together all of the information that we hear anecdotally as far as wait-times to be able to get in to see a provider, and then some providers saying that they are taking new patients, but in reality they're taking cherry-picked patients, patients with commercial insurance. They just simply can't afford it with the low reimbursement rates to take Medicare and Quest patients. And I did want to share one statistic right off the bat, 30 percent of our population in Hawaii is currently on Med-Quest, which 100,000 more than we've ever had before. Judy Mohr Peterson said that during the pandemic, we were still being able to keep up with those, but she said that once the community opened up and people were going to be going back in and getting services that they put off during COVID, that we were not going to be able to keep up with the demand. And that is what our survey is showing, is that very extremely times, four and six months, for folks to get in for cancer screenings and treatments. Our folks are dying on the neighbor islands at a greater rate than they are on Oahu, and we die of things that they don't die off on Oahu, and they certainly don't die of on the mainland, and that's just not what our community deserves. Page 2 HSSSC-16 April 5,2022 And so we are really excited to share the results of the Hawaii County survey, and then tell you where we're going from there with it. CHR. LEE LOY: Ms. David,just for me to recognize Mr. Richards has joined the meeting. Go ahead. MS. DAVID: Thank you, Chair. Go ahead, Mr. Kurohara. Whenever you're ready. MR. KUROHARA: Okay. Yeah, I just want to probably just share a little bit about the campaign. So Hawaii Island, we started off with Hawaii Island as far as doing health-needs assessment, which is done online, and we also did focus groups. So we did ten focus groups, which consisted of a series, a variety of like a medical professionals, hospitals, FQHCs (Federally Qualified Health Care Centers), private physicians. We did social services providers and other members of the community, as well. Let me progress to our slides. So the role of Community First is really to convene. Our main role that we play in the community has been bringing people together, stakeholders, government, policy makers, and mainly our medical and social service providers; and all with the intent of serving as catalyst to sort of improve health and access to health care. So the goal of this project, or this campaign is to better understand the needs of our community with regard to access to timely healthcare or quality healthcare. Because at the end of the day, our vision is that everyone on Hawaii Island has access to quality and timely healthcare, close to home. So we started with the pilot on Hawaii Island. We started in the month of November of last year, and as many of you may know and have actually helped us, which we want to thank you for as well, is getting out a survey, again online and also delivered with our boots on the ground crew, that we're really proud of, that really did a great job in showing up at supermarkets, at farmers' markets, at vaccination sites, to actually make sure that we have access to these surveys especially in areas around the island where we thought we needed to really push it out on. So these are areas that don't normally probably respond to surveys but wanted to make sure that we have their voices heard. And again, through our focus groups as well. And again, I wanted to mahalo all of our partners. We had a lot of people that came to help us. A lot of our partners included the County Hawaii: HMSA; Hilo Medical Center Foundation; the Rural Health Association, as far as our project partner; Hilo Medical Center; and the State hospital system as well. I'm going to turn it over to Lisa. Page 3 HSSSC-16 April 5,2022 MS. RANTZ: Thank you, Randy. He did talk a little bit about the methodology. We really wanted to get the community voice involved in this. There's been a lot of outreach and push from the provider community to let our policy makers know that they struggled with low reimbursement rates, the burden of the General Excise Tax. As you may be well aware, the hospitals and the FQHCs are not burdened with the General Excise Tax, where we're putting that on solo and small practice providers who are providing the frontline services to our community members. Then the General Excise Tax, based on the survey, community members are putting off care and it's primarily our Native Hawaiians, our Asian Pacific Islanders, our Hawaiian Pacific Islanders, because they have to make the choice. They don't know how much the additional fees are going to cost them or what that tax is going to be. So they put off getting preventative services. They're not getting their screenings, have higher incidences of chronic conditions, they just accept that when they're in their late 20's or late 30's that it's okay to get an amputation due to the diabetes instead of getting their medications with something that could very well be managed. And that iswe need to change it, and that's why we're doing the access to care project. We collected 2,248 surveys. Two hundred twenty-five of those were from providers across the island and on the initial results—so one of the questions we asked is what is their perception of the health of the community, and 45 percent of our residents categorized it as unhealthy. So four in ten people feel that way. And then the majority of the providers surveyed, over 90 percent of them are full-time practicing on Hawaii Island, they flipped those numbers, because they're taking care of those chronic conditions; and 59 percent deemed the community as being unhealthy. Folks were able to go in and choose other indicators, and we do have a full report that we can email to you. Nice, beautiful, where you can get all the information and along with the two-pager. So what we're hoping to do is form more groups after the statewide launch is complete. We're currently taking surveys through the entire month of April, and report should be done the end of June. Then at the annual workforce summit that the Area Health Education Center puts on, we're going to form a workgroups to actually come up with demonstration projects or pilot projects on each island based off of the data that comes up from the survey. So this isn't a one and done, this is like we're done studying it, we're taking all of the other studies, pulling them into this one, and then coming up with viable solutions that will make an impactful difference. So that's why we wanted you to be in the know and kind of be able to pick our brains today about that. Page 4 HSSSC-16 April 5,2022 But affordability of insurance and medical care came in at 55 percent, which is really showing that we need to do something to make it more accessible for folks to get healthcare services. So workforce shortages came up as a huge indicator, more than—well, 76 percent of community members said that they can't get care because of lack of access of providers within the community. And their waiting times, you can see on the chart that's on the screen, are waiting more than a month. And in fact what we're hearing is for referrals to specialists, folks are waiting four and six months in order to get in with a specialist, and that's including cancer care. So there will be a story tonight on KITV News at 5:00 and 6:00 that addresses some of that, and they actually are speaking with a cancer patient on Oahu. But I just actually received an email yesterday from a woman in her early 60's that waited four months to be able to get in to get a diagnostic treatment, and she definitely has cancer, and it's an extreme one. So that's heartbreaking. So working through her providers to see if we can get her voice elevated so that we can start highlighting that these are real people behind these numbers. So more on that. But we're experiencing shortages across the spectrum. It's not just physicians, it's our—you know, community health workers, first of all, should be reimbursed through insurance, bottom line, because we need our patients to have the coaches and that management. So that's one of the things that we're seeing rise to the top. But for providers at the State level, or State Legislators, when they say, "Oh, we'll just APRNs (Advance Practice Registered Nurses) or PAs (Physician's Assistants) to provide primary care if our providers reduce hours, leave the island, or go to the mainland. So if we don't have enough physicians, we'll use our mid-levels. But we have shortages of mid-levels. And then when we look at telehealth services—we just had a primary care provider leave our in the end of December. She was providing more care via telehealth to mainland patients to support her primary care habit. There are radiologists in North Hawaii that are only seeing and reading scans from the mainland, because they get better reimbursement rates. They are not seeing patients in Hawaii. So when we look at the list of folks that carry licenses within the State, when we scrub that list down to those that are actually taking care of patients, our shortages are much larger than what they appear to be. So working with the Congressional Delegation is very important. Things like the Health Profession Shortage Area Designation that we worked on through Community First to get County-wide. We were actually successful in getting County-wide designations for the entire State. So a lot of the things that we work on here on Hawaii Island are actually benefitting our entire State. We've heard recently about two Physician Assistants on Maui that are going exclusively to providing care online via telehealth. So that is a slippery slope. It gives us access, but it also prevents access. And those that need the access the most, what Page 5 HSSSC-16 April 5,2022 we found in our survey is that the elite white citizens that have good broadband can access telehealth, but those that live in more rural or remote areas do not have the access to it. So yeah. Sorry, I can talk for days. Obviously this is a passion area for us. We want to be able to bring our kiddos back, and I'm lucky enough that my sons came back, their veterinarians, graduated from UH (University of Hawai`i), took over their mentor's practice, but they struggle, right? So they live with mom. I'm happy about that, but I don't think they want to live with mom forever. So, I would be happy. My goats would be happy. But yeah. So I talked about this a little bit already. Then, did you want to talk about the shortage pieces? Okay. So in the survey results, obviously we've always had some mental health shortages as far as providers, but during COVID, we're seeing that exacerbated. Even in our younger populations down to elementary are really struggling. Through the Rural Health Association, we developed a program called Youth Telehealth, which is providing free mental health and behavioral health counseling, and we can also prescribe providers can provide for substance abuse as well. But that's not solving all of our issues. So widespread shortages across the spectrum, especially with specialists, social services as well. Then of course the economics which I also touched on. So you can see, you've probably already taken a look at this, but we have equity issues as well. And then how are patients impacted? So they're sicker. So I kind of wrapped all of this up,just talking off the top of my head and not going off of the slides. This one is frightening. This is from our providers, 49 percent of those surveyed are considering reducing hours, 47 percent are considering leaving medicine altogether, and 44 percent are preparing to move to the mainland. S So it's not all gloom and doom, because we do have good relationships. And like I said, we're launching—here's our postcard that we're getting out all over the place, but we really want to form that broader voice to be able to form systems of care, and as Randy likes to call it. MR. KUROHARA: So the vision again was to ensure that everyone on Hawaii Island has access to quality healthcare, timely healthcare, close to home. So that that would require is all of our provider groups kind of working together. And the great thing is that during COVID, we saw that. We saw a lot of people that normally don't work together actually come together, share information about what each one is doing, you know, see how they can kind of work off of each other so that we're not, you know, missing any groups out there. What the survey will show us is where these gaps are and how can our providers, you know, again right, work together, again, you know, in a way that across the Page 6 HSSSC-16 April 5,2022 island. Because one is we're a very big island, we're very spread out. We have a lot of rural areas with access issues, transportation is one. So our medical, our social service providers, in a way that puts community at the center of it all. Okay, it's not necessarily their bottom line, but what's best for the community. So our goal is, again, to convene everybody, you know, to want to come together and learn about how everyone can play a role in providing better access. And you know, again, the challenge is huge, because again, we're facing workforce shortages, physician shortages as well. So that part is another piece that needs to be addressed as well, but I think it all starts by, you know, we all working together. MS. RANTZ: Yeah, the other piece is we're getting information from the insurance companies as far as what's being flown off island by procedure code. So we are engaging with the organizations, both the Department of Health, the FQHCs, the hospital groups, to be able to really understand where insurance companies can put their recruiting dollars. So if we have the population to support a specific specialty, then that's what they can recruit for, right? So it's more targeted and then forming sort of centers of excellence I think Randy calls them, where you can provide a certain type of medical service. So with Hilo Medical Center having two catheterization labs now to take care of heart conditions and do stints and vascular surgeons and all this type of thing, it doesn't make a whole lot of economic sense to also set it up in North Hawaii and also in Kona because you have to to get the equipment, you've got to get the three cardiologists and then you need all the support staff to go along with it. So if we can form those centers of excellence for certain pieces of healthcare across the island, then we can look at where to best put our economic resources so then—you know, maybe it's a trauma helicopter to be able to fly people to where they need to be to get that particular type of care. So really forming—working smarter, not harder, then having that collective voice across the neighbor islands to pull resources from Oahu to the neighbor islands. But unfortunately what we're starting to hear is they're having similar shortages on Oahu. So, you know. MR. KUROHARA: Yeah, I think we refer to it as just keeping as much healthcare as local as possible. So if we can afford it as an island and it will prevent, or at least give people an option of not having to fly, then that's what we want to do. MS. DAVID: Thank you. Boy, I'm really sad now, you know, knowing the situation. I already know that we have so many shortages in healthcare. I think your program is totally linked with the State and all the other agencies that have to try to coordinate something so that we can achieve this, right? And right now, Page 7 HSSSC-16 April 5,2022 the health insurance is a big, big problem. Because I do know what you're saying, that some services they won't give you, and it's really hard for people, I can imagine, that don't have the kind of insurance coverage that working people do have. And even when we—for us it's difficult, so I can imagine for those that don't, how desperate that might be. So I'm not sure if I have any suggestions. But I really thank you guys for actually brining that awareness to this body and the public. I think it's something that we already know, but the details is frightening. But anyway, Chair, I yield for my colleagues' questions. CHR. LEE LOY: Thank you, Ms. David. I want to recognize for the record that Mr. Kaneali`i-Kleinfelder has joined us. And now, open it up for questions from my colleagues. Ms. Villegas, go ahead. MS. VILLEGAS: Thank you. Your passion comes through loud and clear. I appreciate this work that you're doing, and bringing the data points because it's, you know, the coconut wireless is never off the hook. And the story of not having enough doctors and why doctors don't want to work here and what not continues to be told. But these specific details provide a parameters for then how do we solve that, right? How do we inspire people to participate in the medical field. On a personal note, my daughter graduated from UH with a degree in kinesiology sports medicine, and thought she was going to become a physical therapist, and ended up becoming a mom. And through the pandemic, the opportunity to become a medical assistant. She got that certification. She's going to be working in the doctor's office for the next year and then wants to get into the PA program, which a woman that's working in the office, she's now working and just did that. So I'm grateful for the PA program on the west side, and that that's opening up for our young people to enter into medical fields. MS. RANTZ: What's excellent actually there is a bright spot that we should mention, that you are actually alluding to, is our Workforce Pipeline Activities. And so the Hilo Medical Center Foundation serves as the Area Health Education Center. And we work very closely with the PA program. We bring students over from jobs, some on the rural training track. We go out into the high schools and do teen health camps and hands-on activities to help recruit our youth into health careers, because they don't know what they don't know. You know, trying to like—some legislators have branded, you know, "Come practice in paradise." That's not the message that we want to put out when we're trying to recruit providers to come to Hawaii. MS. VILLEGAS: Exactly. Page 8 HSSSC-16 April 5,2022 MS. RANTZ: Because we're getting providers that are older, that this is their retirement job, and that's not what we need. We need students that have ties here. We need to put in infrastructure so that when our students go off to the mainland to school, they have a path back. And so through the Workforce Pipeline Activities, we engage them in the clinical activities. We're actually purchasing a house to house all the students on rural rotations, right on Laukapu Street, to be able to make that possible. MS. VILLEGAS: Thank you. That's exactly it. We consistently talk about, you know, the brain-drain, right, and everybody leaving. And I firmly believe that there are folks in the medical field that happen to live in the mainland, but would love to come home to family. So it is that relationship and connecting and communicating, and removing a stigma or a stereotype, or even the fear of working in the medical field? That it's like, "Oh, that's too hard for me, or my brain doesn't—" There are so many capacities to serve in the medical field. And I really feel like it benefits us as an island to have our local people, who have an innate understanding of the societal, cultural, socio-economic, you know, the relationshipping in that, which—it's great that everything goes online and you can get things from your doctor, but just like you said, "White, wealthy, privileged is the computer access, whatnot; but to other folks that's just not a given. And it breaks my heart, what you were saying, people aren't getting what they needed, and that's just another part of the gap, right? Cannot afford a home, can't afford medical, can't afford these different things. I also think that the medical insurance industry is a sham at this point. And it's like there needs to be changes. It's not okay for that much money to be played and to be dictating our community's wellbeing based on what they will or won't pay back. And so it's like a game, right? Somebody sits there. Remember in the "Incredibles,"the movie, and the dad before they—he was like hiding or whatnot, and his job was to deny medical claims, and the older that came would not let him stop? I just thought that was like this profound scene, of like somebody sits in a room and decides, and tries to find every reason to say "No, we're not going to take care of you," and I don't think that's pono. Beep, I yield. CHR. LEE LOY: Thank you, Ms. Villegas. I know the scene you're talking about, actually. Mr. Richards. MR. RICHARDS: Thank you. Long time no see, Randy. Good to see you. You know, you bring the about—well, actually first question, telemedicine, is that part of this? The whole access point, we have geographical challenge, we all know that. We also have a prioritization of how we get into the healthcare line, and that's also a challenge. And we've gotten to a part we are more centralizing. We talked about this, this morning with Fire, about having the urgent care, the rapid care, here to stabilize and get to the centers. The problem is, and you talked about Page 9 HSSSC-16 April 5,2022 it, not having enough resources, we don't have the resources because we don't offer the opportunity. And, you know, you get out of school and you have hellacious debt, and you have to pay that back somehow. So how do we deal with that? And I think that's something that we need to look at closer at the the counties not going to deal with it. The State and the feds are going to have to deal with that. But that's part of the mix. I know for this island—and I know there's different programs. I haven't looked at the human medical side, but even for usI'm a veterinarian, too. I don't know if you know that. I'm trying to hire vets. We want to hire two vets right now, and probably another one in a year. Very difficult. I know that there was a ranking of need in a community based upon the number of licensed MDs (medical doctors), and that's at a federal level. And I know one of the challenges that we had in this County pre-COVID was that we had a lot of retirees that keep their license active, so thereby it looks like we have a lot doctors here, but they're not practicing. Is that still a problem in the numbers? MS. RANTZ: Yeah. So that's what we worked on through Community First, with getting the Health Profession Shortage Area designation. And so the first step was getting that list of everybody that carries a license in the State, and then scrubbing it. Say this gentleman is 90, this is his home address, this one passed away, this one move to the mainland, this one is only providing cosmetic care, they're not doing any gynecological services, and so we go through and scrub the list. But the problem is even with getting the Health Profession Shortage Area Designation, that qualifies our students for the loan repayment. So we do have a couple of programs that we manage now, too. One of them is the Barry Taniguchi Health Profession Subsidy Program. We have Hawaii Island Access to Medical Care Fund for students that graduated from a Hawaii Island high school. So it's not just a State and federal problem, it is a County problem, and everybody needs to get involved because it's everybody's kuleana, and that's how we're going to solve it. And so we do have some of these programs in place, currently both at the Hawaii State Rural Health Association and at the foundation to really help make a difference on those pieces. And then on the Congressional level, what we're working on for noncontiguous states, is to get a because they do a ranking, basically from zero to twenty-five. And then this year though, you know, fund down to a much lower score to place students that registered for something called National Health Service Score, and National Health Service Score is they pay for their schooling or they pay off their loans, and then in turn they go to work for like a federally qualified health center or a nonprofit in a rural area to get their loans paid down. But we can't even bring back our students that graduated from Kea`au because our scores are too low, and our scores are low because of the proximity to the hospital. We still Page 10 HSSSC-16 April 5,2022 have rural areas. We don't have economies of scale, and so we really need to get a ceiling floor. Or it doesn't matter if they're from here, they graduate from here, they trained at UH, they did clinicals here, that they get automatic placement, right? MR. RICHARDS: Okay. And that's where's I'm going with this because once again, I think part of this—and I appreciate the comments about the ranking because of licensed MDs, but they're not practicing, so that skews us. But then also geographically we are still very rural, and this is—and everything we look at and our population-base, and maybe if you do it by MDs per thousand or whatever, on paper it doesn't look too bad. And I don't know the ranking, but this is my point, once again we're still very rural; and then to have that secondary care is going to be off-island, which makes it even worse. MS. RANTZ: Right. MR. RICHARDS: So how do we, at this body level, support this initiative going forward? Because I agree we're not going to fix it, but we sure can take a swing at it. MS. RANTZ: Right, and I think it's the collective voice. And that's why we launched this project, because the bigger the voice, the better chance we have of getting some federal things passed. Because some of it—it needs to start there, but there's things that our State legislature could do as well, because we're rural and remote. And so working with CMS (Centers for Medicare and Medicaid Services) to get the Medicare rate raised, will raise the rate across the board. Because HMSA and insurance companies—it's a standard practice across the nation, is they based the rate off the Medicare rate. But when your Medicare rate is more in line with rural Ohio, which is what ours is, and not like some place like San Francisco, which is more accurate, then you can't afford the cost of living to be able to be in practice. MR. RICHARDS: And this is the paradox. MS. RANTZ: Uh-hum. MR. RICHARDS: You know, we're going to have start by starting somewhere. Just starting. So I like the way this conversation—and I want to follow up with you on this. Randy, you know how to find me and we'll talk story. But that's a concern, because we all grew up in rural areas. You know, I still do primary human care, which is kind of funny. You know, when you come across an accident, you're going to deal with it, right? But the point is just because we don't have those resources. So I really appreciate this, and I want that presentation, and I want to talk story about this. Thank you, Chair. I yield. Page 11 HSSSC-16 April 5,2022 MS. RANTZ: Definitely. We're happy to sit down with any of you and talk about it. And once we compile the results, we want to talk with the health liaisons at the Congressional offices. We are currently working with Ed Case's office and Shatz's (Brian) office as well as CMS. Because what they've been asking us for is proof in numbers that it's more expensive to provide medical care here. Are you kidding me? And then, you know, the kicker on this one is that all of the providers signed agreements with the insurance companies to not disclose what they make. So how in the world do you expect me, or any of us, to get that data that the Congressional leaders need to be able to make a difference? And so my request back out—there was a gal in Shatz's office who now is back at CMS, and so I want her to give me indicators. That's the easiest way. What are the five things that you need to know about a practice, that you can compare to show that these five things are more expensive on the non-contiguous states are inHawaii than on the mainland? So that's what I'm asking for that; so then maybe we get them the numbers that they need to move something forward. MR. RICHARDS: Quick follow-up, Chair? I think there's some procedural things that we can talk about, as well. For me, I had a bad shoulder last summer, and it had to have an MRI(Magnetic Resonance Imaging), but you can't an MRI unless you have an x-ray. That's a ridiculous policy. I mean, an MD should be able to make the determination. They know what they're looking at, so let them make the call like they used to, because that's all changed. Look forward to working with you. CHR. LEE LOY: Thank you, Mr. Richards. Ms. Kimball, go ahead. MS. KIMBALL: Thank you, Chair; and thank you, folks, for being here today and for the presentation, which is a lot of unfortunate news. And thank you, Chair David for putting this communication forward. You know, Council Member Richards kind of indicated, and you folks talked about, you know, a lot of jurisdiction over some of these issues falls at the State or the federal level. But I am curious, and particularly when you talk about infrastructure, and I know you don't necessarily mean what we think of when we think of infrastructure. But do you have bulleted lists of things, at the County level, within our jurisdiction, would be helpful at this point, beyond just advocating at the State and federal levels, which of course we're happy to do for you folks? But are there specific County action items that you think would be helpful in moving forward on this issue? MS. RANTZ: So last year through Shippers Wharf, which actually did receive $100,000 to support loan repayment. So that would be huge to be able to carry that forward so that we can control what that narrative looks like. That is a big Page 12 HSSSC-16 April 5,2022 piece to be able to do that. And the way that we structured that was it can be a match as part of the Hawaii State loan repayment funding, so we're leveraging the dollars. It can also go to the hiring practice because that's the other piece. If we are short in the State, 732 providers, where they all going to work? We don't have the infrastructure to employ them. You know, the practices—even the hospital struggles. So when they bring in a provider, even a family-medicine provider, it cost them about$500,000 before they start really making money for themselves. So it's just sort of like a Catch 22. But we can actually offer some incentive monies to the hiring practice to be able to offset the salary. It takes about two years before they're completely up and running and making money for the practice. So that is one thing the County has done. And then with the housing piece, because we currently rent a house in Kona to support the rural rotations to get them in the community, and it's paying off, and so we've got data to actually show. We've been doing it long enough now that— we hatwe have an OB (Obstetrician)that was hired over in Kona. You know, we're seeing the pipeline now finally start to take route and people being able to stay here. And then if we can some of the fundamentals changed so they can get their loans repaid through the federal government, and just, regardless of score, we can place them. That would be fantastic. MR. KUROHARA: Sorry, if I could just add? So once we get a chance to convene and get everybody on the same page, it's really about sharing the findings of the report, and looking at, let's say what can the County government do? So like we come up with, you know, a list for a related, like a policy maker here or on Oahu, you know, the State level. But the whole goal is, yeah, is to identify actionable items that everybody can have a piece in the puzzle to make this like a better place. Transportation sounds like something that you folks do, and are getting better at, right? You know, that's a big piece. But yeah, so once we can get through this and get a report and be able to convene, you know, I think you'll see a list of things that, perhaps at the County level, you folks could help us with, yeah. And what we haven't talked about as well too, is just—you know, throughout the pandemic we've seen this, right? There's also a trust issue with, you know, when it comes to health and healthcare. So I think that's something that we're being more informed of. And I want to mahalo Doug (Adams) back there, and the work that his team is doing with us and doing the work on health project as well, Health Literacy project, because I think that's really important. That's another piece. Thank you. MS. KIMBALL: Thank you for that. You know,we look forward to continuing to work with you and your working group. And I think you have a very Page 13 HSSSC-16 April 5,2022 action-oriented Council here that is looking forward to really support community-led projects with whatever processes we can do to help enable. I just want to touch briefly onI know in previous discussions I've had with medical professionals, tort reform and malpractice costs were also another significant barrier, and I don't see that mentioned here. Has that been addressed in some way in the past couple years? I haven't looked at this for a while, but no, it's still a problem. It's just not on the list at this point. Okay. MS. RANTZ: That will probable rise to the top. We were really looking more of the access and some of the barriers, and some of those pieces came out in the focus groups as far as that. We've definitely lost providers because of that. MS. KIMBALL: Okay. Thank you. Yeah, I would love to get the full report. I have a couple of folks in my community that are really passionate about advancing rural health. I would say that, you know,just doing community outreach over past few years, health issues are probably in the top four of the priorities that come across in my district, which is kind of an aging district, too. So look forward to more from you folks and more from your working group. Thanks again for coming in. Thanks again, Chair, for the introduction. I yield. CHR. LEE LOY: Thank you. I know you want to go, Ms. Villegas. I'm going to let Mr. Inaba. Go ahead. MR. INABA: Yeah, thank you. Really quick. Just wanted to mahalo Chair David for bringing this communication forward. But the data and the work that you folks doI mean, one of my immediate family members has been dealing with cancer and having to go to Honolulu for treatments. We've had oncologists in Waimea constantly turning over. So, you know, it's been the practice of each of our family to commit to someone who is not going to leave on Oahu. And fortunate for us, you know, we do have the ability to do the telehealth kind of thing sometimes. But the points brought up in this presentation, I think, really highlight, you know, the wide spectrum of issues, and all those outlying components that affect how our community is accessing, or has access or doesn't have access, to healthcare. Like Council Member Kimball said, I mean, to the extent we can be provided with the most detailed action steps as Council Members, whether it's in our own capacities or in advocacy on behalf of our constituents, please let us know. And hoping to have more of these conversation with you folks, and the good work that you do. So mahalo nui. Chair, I yield. CHR. LEE LOY: Thank you, Mr. Inaba. Ms. Villegas. Page 14 HSSSC-16 April 5,2022 MS. VILLEGAS: Yes. And just being able to have this conversation, and hearing that you're going to go into high schools and starting to talk to our young people, because as the world gets a little crazier and crazier out there, I know for me growing up it was always like you've got to go away, you've got to get out of here, you've got to da-da-da-da-da, and there's wisdom in that. But there are a lot of our young people that want to stay here, that want to serve and have a role and purpose within their community, and providing that avenue for medical assistance. I mean, it wasn't horribly—it was totally doable for her, which I thought was great. She's also a college graduate. But something we've since discovered is now in her work she's considered an essential worker. So childcare becomes a real challenge also for women who are mothers, you know, trying to return to work in the medical field, but they cover completely her childcare because she's considered an essential worker. Now I don't know if that's because of COVID or, you know, whatnot, but I mean that's just a huge benefit that comes along with educating people that facilitating you know, doctor is this pinnacle, but physician's assistant essentially does what the doctor does, too. And there's a difference in education, and a difference in the loans you end up saddled with. I do want to hear about the potential for loan repayment based on working in the medical field, because we've got lots of those from just, you know, UH-Manoa. But thank you for this. And I'm hoping people out there are listening, and this will get picked up and broadly distributed as that solution and how to participate. So thank you. MS. RANTZ: You're welcome. And thank you so much for sharing your personal family story. I really appreciate that. The Department of Health or the Department of Labor came out with their top living-wage jobs, and healthcare was at the top, and a very distant second was IT (Information Technology), and third were our skill trades. And so if we don't take advantage of that, you know, seeing that the hospitality industry doesn't do it for our kama`aina, then we need to pivot and shift and let them know these living-wage jobs exist, and they don't have to be a clinician, right? But let them know, like I said, they don't know what they don't know. But I think that is something that we can embrace at the County level to like at least to help what's going on here, boots on the ground. MS. VILLEGAS: May I add something just for a quick second? CHR. LEE LOY: Go ahead. MS. VILLEGAS: And going back to what Mr. Richards said and what I said earlier, the challenges with insurance companies. I know I needed an MRI on my neck, but I had to do physical therapy, and I had to do, yeah, this, that, and the other, and then I needed a cortisone shot, and I had to fight to get it, and that adds Page 15 HSSSC-16 April 5,2022 fees to the person who doesn't—and then you get the bills. You get them later, it's like, oh, $200. Oh, $50. Oh, $50 for that, not to mention the time and managing. I can't get my husband to the doctor because of that. He's like, "I don't want to get a bill, and"you know. Anyway, working that's a lot of State and federal. So thank you for your work, and reforming some of those practices and procedures, because humans, we have an uncanny ability to complicate things. So, thank you. MS. DAVID: If anyone else yeah, go to them first. I spoke already. CHR. LEE LOY: Yeah, I want to go to our Council Members who haven't had a chance to speak. Mr. Kaneali`i-Kleinfelder .. MR. KANEALI`I-KLEINFELDER: Thank you, Chair. Thank you for the presentation today. I'm thinking back, about three years ago I was meeting with some of our local primary care physicians, and what was interesting, what caught my ear was that there issue was getting reimbursed. It was simple. Like, if we don't get reimbursed, we don't get paid, it's not worth it. So either we can see a huge amount of patients so we can get the small reimbursement per patient, or we can really focus in on our clientele, which forced some of them to go to a different model all together. You know, basically we're going to skip doing insurance, and you can pay to have our services. And that, to me, that really just, it struck a chord because we're dying for physicians and yet we can bring them in, or they won't stay, even though we're in Hawaii. And it's a well-paying job, but they're not getting reimbursed when they go in for reimbursement. And they're going to have a fight for the reimbursable cost, and that really drove it home for me. So I don't know if that's still an issue to this day. It is, yeah, okay. Yeah, that was three years ago, and I didn't know what to do at that point. Brand new legislator to the County Council. What can I possibly do? But that really showed some light on the problem for me. And some of the doctors have actually switched their model all together, and they're not changing. They're just—they're content. MS. RANTZ: Concierge medicine. MR. KANEALI`I-KLEINFELDER: Yes. That's what it's called. MS. RANTZ: So $200 a month, $400 dollars a month, whatever it is. But that just goes to the health in equities, and further the disparities in the gap in socioeconomics. And it's unfortunate, but that why this is the only thing that we could think of to do, Randy and I, to really move the needle forward, because we keep hearing it over and over again. And the time for studying is done. We need Page 16 HSSSC-16 April 5,2022 to get the work groups and we need to come up with the action items. And thank you all for wanting that list. We will work hard on getting the list of things to do. MR. KUROHARA: And, you know, short story. My brother's a family doctor, right, so he's been at it for many years. So I mean, fortunately, he got into the practice at an early age. I mean back then when you could actually develop a clientele. But for somebody new today to start, it's really hard. And that's why you don't see too many, you know, independent doctors, right. They all are getting employed by a larger systems. And perhaps that's the future. But at the same time we really want to make sure that, for Hawai`i Island, that we can preserve as many of these independent doctors as possible, because that's sort of what we grew up with. And I think a lot of people like that access in choice that you have. But it's just a hard model to make work today based on the economics of healthcare. MS. RANTZ: And some of that was the changes in the federal government that they pushed down with the mandates for quality scores and making sure they're getting mammograms, making sure that they're, you know, meeting these markers. And so instead of seeing patients, our providers are spending time does all of this data input and metrics gathering information for the insurance companies. And then the insurance company is saying, unless you give me that data I'm not going to reimburse you. So that's where some of that comes in. But that came from the federal government with the changes they passed down. MR. KANEALI`I-KLEINFELDER: Interesting. It shines a pretty clear light of what changes we need to make. And I have to say I didn't realize how lucky we were to have a PCP (Primary Care Physician), because friends of ours were asking, "Hey, you know, if that doctor was available." And I was like, "Yeah, sure." And I call him and he's like, "I'm not taking new patients. I haven't done that for years." Which explains to me very much how we have such a shortage, and it's not apparent until you go look for a new doctor. And as a parent, and you have kids, and you're trying to get them in to see somebody and you can't actually find a doctor. That's incredibly distressing. MS. RANTZ: Yeah. It's absolutely heartbreaking. And when the provider I mentioned left our island, she left so quickly that they weren't able to get all of the records. And the people, the record company that took over all of the medical records have still not made them available to the patients. And so all of these people cannot get in with another provider because they want a copy of your medical record when you're transferring providers. And so they have not been seen for months and they can't get an appointment. And so then their conditions are getting worse or they're flying to the mainland for care. We're losing a radiologist and his wife because they're being denied care, which is unfortunate because they were working on our physician crisis shortage Page 17 HSSSC-16 April 5,2022 taskforce that we started on Hawaii Island, which is now across the entire State. They were at the forefront of that doing economic analysis and were pleased and happy to be here and stayed here even after their son and his wife moved after suffering a miscarriage because she couldn't get care. So they moved to the mainland, but the provider stayed here because they really believed in providing that patient care in a place that really, really needs it. MR. KANEALI`I-KLEINFELDER: Thank you for the presentation again. I look forward to anything you can kind of give us to help us find a good track to get more doctors here for our community. Thank you, Randy. Thank you, Lisa. CHR. LEE LOY: Thank you, Mr. Kaneali`i. Ms. Kierkiewicz, go ahead. MS. KIERKIEWICZ: Thank you, Chair. Really quickly. Mahalo nui, Lisa and Randy, for being here. Randy, I think when you were working for Mayor Kenoi as his R&D Director and then Deputy Managing Director, this was one of the primary issues that Mayor Kenoi was so incredibly passionate about. So we knew then, this was a problem. This data that you've accumulated, really outstanding research, but it just highlights how dire our situation is. But I appreciate how proactive you're being in identifying what we can do ourselves, what does the State Government need to do to really solve for this challenge that we have. I'm really struck by some of the comments that are in here. A provider, "I plan to retire in 2012, but have been unable to find anyone I can refer my patients to." That's ten years ago. They're still in practice because of how compassionate this individual is. If they were to leave, who would care for their patients? "I had two of my doctor's leave or reduce their hours. My PCP left so I'm being cared for by a nurse practitioner. My dermatologist has also reduced office hours." Folks are feeling incredibly burdened by all the care that needs to be happening. "Isolated rural populations not sufficiently served by telehealth." Really important to push the state and county on where we are with increasing access to broadband services. Vibrant Hawaii, I think you guys know, has convened a digital literacy project. We're putting laptops into the hands of kupuna and individuals that really need them and teaching them how to access healthcare providers. So important. And I think a lot of this really lends itself to and aligns with the physician shortage report that I think you all were part of that Vibrant Hawaii pulled together. We have to do better. We have to do more. MS. RANTZ: And getting devices into the hands is one thing. But being able to afford the broadband is a second thing. MS. KIERKIEWICZ: It really is. Page 18 HSSSC-16 April 5,2022 MS. RANTZ: And so that in and of itself is still difficult. So we can do the training but glad so we can get the laptops in their hands. We can train them how to participate in telehealth. But if they can't afford the service or if the service is spotty, then it just becomes a paperweight. It's unfortunate. MS. KIERKIEWICZ: When you pulled together your report, and I know that this one sheet that you have here with the survey results, this is just very high-level snapshot. I'm sure you have by district or even regional level what the needs are. Please let us know what it's going to take to get every single type of provider and specialist needed to take care of this population in that report. I have an immediate family member whose breast cancer came back for the second time. She had to get a mastectomy and reconstructive surgery. She couldn't get care because of the pandemic and once doctors were available, she was completing with the rest of folks across the State that were trying to get this surgery. So there is a need to support our population. So you have to have a report that identifies what exactly we need to support, not just the population we have right now, but we've got to take a look at that 10-20 year horizon so we're supporting folks and their needs. MS. RANTZ: Yeah,part of what we're doing is,with that snapshot in time of the providers that we have in the State that carry licenses is working with FEMA to map it out, because it becomes important if we do have a natural disaster to know exactly what services we have where in which zip codes and how we can mobilize our medical services. So this is a pretty big project. And we have the telehealth Pacific Basin as part of it, because it's a great service, but we need to make it so that it's accessible. And it's really hard with our geography. MS. KIERKIEWICZ: Sorry, could you just expand a little bit more on the cultural competency of the workforce? Is that I mean you talked about all the great work that you're doing going into high schools, letting folks know about job opportunities in the healthcare fields, but what more else needs to happen? MR. KUROHARA: Yeah. So I think what's reflected in that statement is with regarding being able to better connect with the people in the community regarding their health, right. So again there's a little bit of a disconnect right now, and we've seen it during COVID, right. There's a trust issue. It's maybe learning how to explain things in a way that they can understand it. You know, as a provider we just take for granted that people understand a certain level of healthcare language. But we've seen that,that's not true. You know, so Page 19 HSSSC-16 April 5,2022 simple things we take for granted. It should be understood, but it's not. So I think there's that piece, too, as well. MS. KIERKIEWICZ: Randy, I think I remember 10 years ago, the Got Dot campaign, right, making sure everybody had a medical home and just kind of breaking down that language so that we can increase access to healthcare. Final question. Are there any ways in which you think you can be leveraging the County's ARPA (American Rescue Plan Act) funds? I think over a year ago we got an update from the administration on how they would like to spend those dollars to solve for some of the issues we're facing here in Hawaii County. Some of that was related to workforce development. Any projects that you have in the pipeline that can increase capacity of local workforce as it relates to healthcare? I know our R&D Director is here. MS. RANTZ: Absolutely. MS. KIERKIEWICZ: By all means, please share. MS. RANTZ: Doug knows I have a million ideas. MS. KIERKIEWICZ: Top one or two. We've got$60 million. Hasn't been spent yet. MS. RANTZ: Excellent. Well I think we should sit down to have a longer conversation. MS. KIERKIEWICZ: Yes. MS. RANTZ: Because I think we really need to look at the shortages whether that's CNA's (Certified Nurse Aid) MA's (Medical Assistant), where we can leverage and make the greatest impact. And so I don't feel comfortable answering that off the top of my head, because I think if we can look at it based off of the data and really make informed decisions then we can do something that's effective and sustainable and moves the needle immediately. MS. KIERKIEWICZ: Excellent. Randy? MR. KUROHARA: Yeah. I'll just say, we're bringing as many people together as we can to better understand. If you're a hospital, if you're FQHC (Federally Qualified Health Center), you know, what are their plans, right, and trying to see how we can leverage what they're already doing or planning to do. And again, and then to identify where the gaps are. And maybe some of those funds can be put towards those gaps. Page 20 HSSSC-16 April 5,2022 So I think one is, you know, future convening and planning around getting everybody to the table to agree to work together to, you know, again solve some of the issues that we have here. MS. RANTZ: It's forming that system of care so it's not convening to do another study, but it's convening to actually say, "Okay, here's what we need, who's providing it, who has the capacity to hire, and what would that look like." MS. KIERKIEWICZ: Yeah. MS. RANTZ: Based off the geography MS. KIERKIEWICZ: It's convening to take collective action. We get it. Thank you. Thank you, both, for your hard work on this. Chair, I yield. CHR. LEE LOY: Thank you, Ms. Kierkiewicz. Ms. David. MS. DAVID: Thank you, Chair. And recognizing our time and you haven't spoken yet, so I'll keep this really short. The withholding of the records,just a personal stance to that, I think that's negligent. And so I'm hoping that they can proceed. MS. RANTZ: They're processing. They're not withholding. They just haven't scanned them to make them available. MS. DAVID: I see. Okay. I thought I'd heard it all. But my question, could you really quickly, and maybe this is something we as the legislative body can assist you guys with. The GET medical exemption bill, what is that? Is that something that we could support? Explain that really quickly. MS. RANTZ: Yeah. So actually in 2020 we were really successful. It was in its very last phase to get the General Excise Tax exempted from medical services. And it was the bill only on medical services. I think the bill that you're referring to is one that gets put forward every year and it's taking off groceries and feminine hygiene products and also on certain medical services. MS. DAVID: Right. It's just a notation about medical exemption. But that's not something—okay. MS. RANTZ: Yeah. I mean, what we really need is, you know, even if the State would be open to doing exemption for healthcare from the General Excise Tax in the HPSA (Heath Professional Shortage Area) areas, right, for Medicare, Quest, and Tricare. That would a huge step in the right direction, if they weren't open to doing it unilaterally. But we are the only state that taxes healthcare in the nation, by the way. Page 21 HSSSC-16 April 5,2022 MS. DAVID: Okay. MR. KUROHARA: Lisa, you might want to explain a little bit why the tax is bad, right, because they cannot pass it on. Yeah. MS. RANTZ: Yeah. So for example, if the price of lettuce goes up and you own a grocery store, you can increase the cost of your lettuce. In healthcare your reimbursement rate is what your reimbursement rate is and it's illegal for you to pass on the General Excise Tax to your Medicare patients. Our tax fact sheet says that it can be passed on, but federal government says that it cannot. And if the provider gets caught doing that they will lose their license. So you're not supposed to pass on that tax so the providers have to eat that. I was invited to the Hawaii Medical Association. They did a dinner on Saturday and was promoting this project and smoozing and,you know, getting them to participate in focus groups and just sort of doing key informing interviews, unofficially getting data. And these doctors are very compassionate. They've been providing care forever. They lose money on the Quest patients. But they provide the care anyway. MS. DAVID: Well thank you so much, both of you, for being here and the information you've provided us and the public. Chair, I yield. Mahalo. CHR. LEE LOY: Thank you. Thank you, Randy and Lisa. I'm going to wrap it up. I do want to continue this conversation, because I have a couple of questions myself. But we have another meeting scheduled. I just have two questions immediately. When you guys were kind of recruiting for the focus group, like from what categories were there Physicians, Social Services? Like what was that focus group made up of? MS. RANTZ: So we did a series of focus groups. We started with letting our State legislators on Hawaii Island know that we were getting ready to launch this, and what we were going to do and then to reach out to their constituents to let them know to participate in the survey. Then we met with the Department of Health, right, as a whole. So we started big with systems, and then the hospitals, the federally qualified health centers, social service, behavioral health, primary care physicians, specialists, and then the community members after they participated in the survey. CHR. LEE LOY: Okay. Yeah. We heard a lot of stories today about, you know, just personal experiences. I have a son with special needs. So we have a team of doctors and that is the most challenging thing to have. We have seven. I mean because it's special and he has special needs. And so I completely look forward to those actionable items. But it would be really neat if we could kind of create Page 22 HSSSC-16 April 5,2022 that center of excellence just around something like that, because those doctors can take care of a whole lot of patients. But those specialized doctors for that group would be a very interesting center of excellence to really think about in inviting care for. So with that, I'll have my office connect with you guys. We do have a motion on the floor to close file on Communication 692. All those in favor please say "aye." Vote on Comm. 692: The motion to close file on Comm. 692 was carried (Filed) the following voice vote: Ayes: Committee Members David, Inaba, Kaneali`i-Kleinfelder, Kierkiewicz, Kimball, Richards, Villegas, and Chair Lee Loy— 8. Noes: None. Absent: Committee Member Chung— 1. Excused: None. CHR. LEE LOY: That brings us to the end. ADJOURN- There being no further business, at 2:05 p.m. Mr. Inaba moved to adjourn MENT: the meeting. Seconded by Ms. David and carried by the following voice vote: Ayes: Committee Members David, Inaba, Kaneali`i-Kleinfelder, Kierkiewicz, Kimball, Richards, Villegas, and Chair Lee Loy— 8. Noes: None. Absent: Committee Member Chung— 1. Excused: None. CHR. LEE LOY: Meeting is adjourned at 2:05 p.m. Thank you. Approved: Welk •n L. K. Lee Lo ,Jhair (Date) b �,. vices and Social Services' ommittee SL/tk Page 23