Access to Care Hawaiʻi Island Report by CommunityFirstHawaii

Access to Care on Hawaiʻi Island Opinion Research Findings

2022

Table of Contents Executive Summary Perceptions of Health and Wellbeing Views of Health Care Access Needs and Solutions Checklist for Change

Page 2 Page 6 Page 9 Page 16 Page 21

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Executive Summary Health care is delayed more than denied on an island deemed “unhealthy” by many who live there. A majority of providers (59%) and a good number of residents (45%) believe their island community is currently “unhealthy.” Hawaiʻi Island residents blame access to and affordability of care more than anything else. The public believes a physician shortage is largely to blame. The providers we queried concur. Despite raising concerns over access, a significant number of island residents – 92% – sought care at least once over the past year. It is also not clear whether the number of visits corresponds to the level of care needed, especially because only 21% report seeing a provider “when wanted.” The providers we surveyed report they are still open for business – at least for now. More than seven in 10 (72%) are accepting new patients and another 17% say “it depends.” Yet more than three-quarters (76%) of the community believes a “lack of physicians” is the biggest barrier to accessing health care services. In addition, delays in care abound – nearly half (48%) report problems getting timely appointments with 19% of those saying the wait times were “significant.” Delays in care are the most profound for residents needing specialists and those receiving government-funded health care. Providers confirm this. In fact, four in 10 (40%) believe the wait time to see any type of specialist – on-island or off – is more than a month with almost two-thirds (63%) of health care professionals indicating the wait time is at least three weeks or longer. All agree that appointment delays are untenable, and off-island travel for care is arduous and expensive. Given the number of providers contemplating reducing their hours (49%), leaving medicine (47%) and/or moving to the mainland (44%), it is only going to get worse. An existing shortage of Physician Assistants (PAs), nurses, Certified Nursing Assistants (CNAs), and Community Health Workers (CHWs) exacerbates these challenges in the healthcare system. Due to COVID-19 healthcare providers are burdened by a mental health crisis; and residents have postponed preventative care. Psychiatry and mental health counseling are, far and away, the two professional areas needed most, according to providers. Medical service needs abound due to widespread shortages in all medical specialties. Increased social service capacity, including addiction and recovery and assistance to the houseless is another pressing

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need, along with more cultural competency. Mental health was also an area where prevention and early intervention was mentioned the most often, starting in the schools. Like many things in Hawaiʻi, it’s complicated. Hawaiʻi Island residents and providers realize important life basics – housing, transportation, and access for healthy, affordable foods – are critical to the health of the community. In fact, they are placed higher on the list of factors influencing overall health by both groups than more “health specific” metrics such as access to exercise. High cost of living and housing woes also make it difficult to recruit and retain physicians and other health care professionals – which is compounded by low reimbursement rates. It explains why so many providers are contemplating hanging it up. “The cost of providing services has increased, but the reimbursement rate has decreased. Tax rates for the GE are cutting into my very small profit margin as I’m not allowed to charge taxes,” complained a Hawaiʻi Island health care provider. Thus, it appears difficult to improve health care delivery and outcomes by building out the necessary medical workforce without addressing the lack of affordable and available housing, and the high cost of living, including access to inexpensive healthy food, not to mention increasing reimbursement rates. Isolation is another key factor impacting satisfaction among providers. The public and health care experts on Hawaiʻi Island also realize that health care delivery is complicated – more so than elsewhere. Our cultural diversity is an asset and a complicating factor that impacts many facets of health care delivery, especially because we are a multilingual society. They realize that health care needs, approaches and stigma are different across cultures and require an increase in cultural competency and language access, especially to the Hawaiian, Pacific Islander, and Filipino populations. As one provider put it, Hawaiʻi Island needs “a more relevant workforce that reflects the community through language, cultural competencies, [and] cultural protocols.” The rural nature of Hawaiʻi Island also compounds some of the problems and, if not careful, could lead to greater health care inequity. Transportation to receive care is not easy for some – and many of these same individuals lack the technology or know-how to seek telehealth, let alone reliable broadband. Then there’s the geography of the state, with the most extensive medical resources concentrated an island away on Oʻahu.

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Equity traps abound. Those suffering the most from the current system, especially when it comes to delayed health care and access to specialists, are Medicare and Medicaid/MED-QUEST patients. Changing the reimbursement rate structure and addressing General Excise Tax (GET) reforms are seen as vehicles for improving health care equity, according to the health care professionals we queried. There is also a tension between increasing telehealth programs for those who seek care frequently and those who don’t. Shifting more of the higher-needs patients to telehealth and home monitoring could have the greatest impact on staff loads and the cost of care. And they are a very willing and savvy audience. However, this is a white and well-educated group – at least on Hawaii Island. Doing so would increase the digital divide and further contribute to disparities in care. Majorities of Native Hawaiians, residents with a high school degree or less, and Filipino men are not likely to use telehealth, and meaningful numbers of respondents (43%) report having “concerns” with this platform. Perceived quality of care and lack of personal interaction are the chief worries, though a range of technology challenges loom large for certain Hawaiʻi Island residents. The moment is now. These multi-layered and broader community challenges complicate the ability to find solutions, especially on a multiethnic, multilingual island with a number of high needs, and rural communities where transportation and broadband are spotty. Many of the providers recognize the moment for positive change in health care delivery is now. To quote one health care professional, “We have opportunities for creating an abundance of positive change to improve health care quality and safety, raise employee engagement, and increase patient satisfaction and care.”Providers report a greater willingness to collaborate, communicate, and coordinate.

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Methodology This analysis is based on a survey of 2,023 Hawaiʻi Island residents and 225 health care providers conducted from November 10, 2021 through December 10, 2021. The survey was administered online via a link or QR code taken on respondents’ computers or smartphones, or on a tablet provided by the community outreach team. In addition, paper copies were also distributed to respondents more comfortable with this approach. All health care professionals who participated in the survey provide care on Hawaiʻi Island in a range of settings with most in private practice (33%) or working in a hospital (31%). Nearly two-thirds (64%) provide full-time direct patient care. Because the survey was conducted online, there is no calculated margin of error. A probability-based survey must be sampled randomly. By sampling and weighting the demographic composition of the survey to the true population, this online survey is a representative snapshot of Hawaiʻi Island at that point in time. In addition, ten focus groups among a range of health care professionals were held online with providers from across Hawaii Island from October to December, 2021. The groups ranged from sessions with two to four key informants to eight to 11 participants. The purpose was to better understand the issue landscape as it relates to health care access. These 60-to-90-minute qualitative sessions included professionals from healthcare systems (Department of Health, hospitals, Federally Qualified Health Centers); Independent Physician Associations; experts in behavioral health and social services; and community members. Throughout this report responses from the survey of providers are reported in blue font to delineate these findings from the community survey results.

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Perceptions of Health and Wellbeing Hawaiʻi Island residents are divided over the health of their community. Stark differences by gender, age, and medical needs. Hawaiʻi residents are fairly divided over the health of their island. While a majority (55%) deem their community “healthy,” more than four in 10 (45%) categorize it as “unhealthy.” Views are not strongly held – just three percent (3%) believe Hawaiʻi Island’s health is either “very healthy,” or “very unhealthy.” Those who seek medical care the most often -– and who find it delayed – are among those most likely to see the community as “unhealthy.” Women (52%) are also much more likely to deem the community “unhealthy” than men (37%). And it is the younger residents who believe the Island is in poor health compared to their older counterparts (49% among respondents under 55 years, compared to 40% among those 55+). Whites and Chinese respondents are divided over the health of the community, while most other ethnic and racial groups are more likely to declare their community in good, rather than poor, health.

Most likely to rate the community as "healthy" Older Filipino (55+) Hawaiian/Pacific Islander men Older Hawaiian, Pacific Islander (55+) Rarely/never used system in past year Older men (55+) Men 65+ years Received care when wanted High school graduate or less education Younger men 55+ years Total

76% 70% 69% 68% 66% 63% 62% 62% 62% 61% 60% 55%

Most likely to see the community as “unhealthy” Younger college grads Younger women (under 55) Chinese women Caucasian women Advanced degree College-educated women Hawaiian/Pacific Islander women 35-44 years Used system 6+ times past year Needed care was delayed Younger Caucasian Younger Chinese Total

60% 57% 57% 57% 55% 55% 54% 54% 54% 54% 53% 53% 45%

While the public is more likely to give the community a positive prognosis, the providers we queried were less optimistic. The medical professionals flipped these numbers with more of the opinion that the community is unhealthy (59%) than healthy (41%). Access to Care Hawaiʻi Island |6

A majority believes access to and affordability of care are paramount to good health. Affordability of insurance and medical care (55%) along with health care access (54%) are considered the most important drivers of residents’ personal health status. This is even more pronounced among Hawaiians, Pacific Islanders, Filipinos and Chinese. Not surprisingly, those who use the health care system often as well as those who have experienced delays put “access to health care” at the top of their lists.

ca See k re of te n ha Hav d de e la ys

Ch ine se

Fil ip ino

Ja pa ne se

Pa Haw cif a ic iian Isla / nd er W hit e

55 yrs +

55 yrs <

W om en

M en

Al l

What services do you require to improve/maintain your health?

Affordable care/ health insurance

Access to health care

Good schools, place to raise kids

Access to healthy food

Jobs/good economy

Low crime, safety

Affordable housing

Healthy habits, lifestyles

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Some point to external stressors, chiefly good schools, access to healthy food, the economy, cost of living, and personal safety as factors important to positive health outcomes. Hawaiʻi Island residents also point to external stressors such as good schools and familyfriendly communities (36%); availability of healthy food (33%); a thriving economy (31%); low crime rates and personal safety (29%); and affordable housing (27%) as determinants of their personal health and wellbeing. Younger residents are more inclined to place higher priority on schools, housing affordability, the economy, and access to healthy foods higher than their older counterparts. Personal elements such as a healthy lifestyle (27%), access to recreation and physical exercise (21%) and a strong family life (19%) are lower on the list. This is also the case with supportive services for seniors (19%), which is considered more important to kūpuna (32%). Access to dependable transportation is also a bit lower overall (18%) but registers higher with Hawaiian and Pacific Islanders (23%), especially men (29%) and those over the age of 55 (34%). Providers also point to factors such as housing, social services, and transportation to improve Hawaiʻi Island health. 71%

71%

65%

61%

47%

38%

Affordable housing

Social services

Access to transportation

Healthy foods

Places to exercise

Safe, convenient gathering spots

Not only is affordable housing a top public issue, the medical professionals we surveyed also point to it as one of the most important ways to improve community health. Housing is not only seen as critical to health and wellbeing, but also a factor impacting the ability to recruit health care professionals to the island. More than seven in 10 (71%) point to housing along with expanded access to social services (71%) and access to transportation (65%) as critical to the health and wellbeing of Hawaiʻi Island. The providers we surveyed were much more likely to prioritize patient access to social services and transportation than the community at large. As with the public, access to healthy (and affordable) foods (61%), a cost-of-living factor, is considered key to community well-being. Venues for exercise 47%) are found lower on the list, as are safe spaces to gather (38%). Access to Care Hawaiʻi Island |8

Views of Health Care Access Most residents sought and received health care on Hawaiʻi Island over the past year. Despite raising concerns over access, a significant number of island residents – 92% -sought care at least once over the past year. This may have been due, in part, to an increase in pandemic-related diagnostic and treatment regimens. It is also not clear whether the number of visits corresponds to the level of care needed, especially because only 21% report seeing a provider “when wanted.” Those who received health care six or more times in the past year are more likely to be senior citizens (34%) and Caucasians (32%), with greatest demand from whites over the age of 55 (39%). They are more likely to have care covered by Medicare/Medicare Advantage (36%), Medicaid/MED-QUEST (34%), or Kaiser (33%) than HMSA (23%). Thinking over the past year, how many times did you access health services? 8%

10%

34%

21%

27%

None

Once

2-3x

4-5x

Younger men under the age of 55 (17%) and Hawaiian and Pacific Islander men (17%) are the least likely to have received care. In both cases, roughly three-quarters reported not needing care. Though one provider suggested a “lack of trust with physicians and health care providers” contributes to the avoidance of care among some populations. Among those seeking care, most were able to find it on island, and, if not, in the state. Fortunately, most (70%) were able to get their medical needs met on island, including roughly half of respondents (49%) seeking care from specialists -- and 71% were able to access a specialist on the island. The main reason for seeking off-island specialists is the sense that the specialty was not available on island (80%). The bulk of those unable to receive care on-island had their needs met in the state. This means that 94% of those seeking medical care on Hawaiʻi Island were able to receive Access to Care Hawaiʻi Island |9

treatment without leaving the state. Though certain residents have a much higher rate of unmet needs, especially kūpuna. Groups most likely to report having problems accessing the type of care needed on Hawaiʻi island include: Older Caucasians (46%) Those with chronic health needs (45%) Medicare patients (43%) 65 years and older (42%) Men over 55 (40%) Respondents with advanced degrees (40%) Medicaid/MED-QUEST patients (40%) TOTAL unable to access health services within Hawaiʻi County (30%) While most residents are receiving what they perceive to be timely health care services, roughly half (48%) report delays in care. This is especially true when seeking specialists. Given the care needs – including a huge demand for behavioral health services – delayed appointments present big health risks to patients and the community.

70% Percentage who sought and received in care on Hawaiʻi Island in the past year

24% Percentage able to find care in-state

94% Total in-state care

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Provider shortages are perceived to be the biggest barrier to health care access. Perceived lack of providers (76%) is what prevents Hawaiʻi Island residents from accessing timely medical care, according to survey respondents. Indeed, more than eight in 10 (81%) believe Hawaiʻi Island lacks an adequate supply of physicians. “I had two of my doctors leave or reduce their hours. My primary care doctor left so I’m being cared for by a nurse practitioner. My dermatologist has also reduced her office hours.”

What do you feel prevents the community from accessing health care services?

- Hawaiʻi Island resident “We are choosing between living where we love and staying alive.” - Hawaiʻi Island resident

76% Lack of providers 56% Cost of care 39% No/inadequate insurance 16% Inconvenient clinic hours 15% Cultural/language barriers

Health care professionals concur. They say lack of providers (84%) is the most pressing issue when it comes to community access. Availability of specialists and practitioners who accept and treat Medicare and Medicaid/MED-QUEST patients appear to be the biggest pressure points. Yet the providers we surveyed report they are still open for business – at least for now. More than seven in 10 (72%) are accepting new patients and another 17% say “it depends.” They also report being able to see existing and new patients within a few days of making an appointment.

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Health care costs and insurance hardships are additional barriers to access for a good number of Hawaiʻi Island residents. While a bit lower on the list, cost (56%) and insurance issues (39%) are lower on the list. It is also worth noting that good numbers of respondents mention a provider shortage, cost concerns, and lack of cultural and language competency as hindrances. The problems plaguing individuals seeking care are not mutually exclusive which complicates the ability to find solutions, especially on a multiethnic, multilingual island. Cost (66%) is a much bigger driver among those who have sought health care services the least, either once or less in the past year. These respondents are also more likely to cite “cost of care” as a reason for delaying health care needs than other Hawaiʻi Island residents and are also more likely to point to the lack of or inadequate insurance as a community barrier to care. Respondents most inclined to believe cost impacts access to care skew younger and include certain Asian and Pacific Islander populations, along with Medicaid/MED-QUEST patients: Younger residents under 35 years (73%, making it a bigger for this crowd than lack of providers) Chinese (69%) Native Hawaiians and Pacific Islanders (67%) Filipino (64%) Japanese (63%) Medicaid/MED-QUEST patients (63%) TOTAL cost of care (54%) Inconvenient clinic hours were mentioned by 16% of the sample. Women, especially Native Hawaiian/Pacific Islanders (26%) and those under 55 years (24%) were more likely to say hours of operation was an obstacle to access. Cultural and language barriers persist for certain AAPI residents, especially those who are older and men. Respondents most inclined to cite this as an access issue on Hawaiʻi Island include: AAPI men who are Hawaiian, Pacific Islander, Korean, Vietnamese, etc. (not Chinese, Filipino, or Japanese) (32%) Older Asians who are Korean, Vietnamese, etc. (not Chinese, Filipino, or Japanese) (28%) Medicaid/MED-QUEST patients (25%) Older Filipino residents (24%) Chinese men (23%) TOTAL cultural or language barrier (15%) Access to Care Hawaiʻi Island |12

Medical professionals also see lack of providers as the biggest hindrance, adding transportation, other barriers to the mix. As with the public, a shortage of providers is seen as the biggest obstacle to health care access on Hawaiʻi Island. At 84%, lack of medical professionals is nearly 30 percentage points higher than the second most identified obstacle which is transportation challenges at 57%. “Transportation services are a lowhanging fruit,” according to one provider. The providers we surveyed believe getting to appointments is more pressing than cost and insurance issues (45%). Administrative burdens (35%), language barriers (29%) and not enough clinic hours (29%) were also mentioned by roughly three in 10 medical providers. Nearly half of the public report appointment delays.

What do you feel prevents the community from accessing health care services? [PROVIDERS]

Delays in getting appointments affects nearly half of Island residents. Forty-eight percent (48%) report delays in services with 19% reporting “significant delays.” Just over half (52%) report being able to access health services when wanted or needed. In terms of who faces “significant delays,” it’s largely an older crowd with chronic health care problems, who rely on Medicare or Medicaid/MED-QUEST for coverage, and are likely to be White, Chinese and female. Those most likely to face “significant delays” include: Sought health care six times or more in a year (30%) Caucasians (29%) Medicare recipients (28%) Senior citizens 65+ (26%) Chinese (26%) Women 55+ (26%) Medicaid/MED-QUEST patients (25%)

84% Not enough providers 57%

Lack of trransportation 45% Lack of insurance/cost 35% Administrative burdens 29% Language barriers 27% Not enough clinic hours 27% Other

Inability to get an appointment was the chief reason for the lag. Nearly six in 10 (57%) say inability to get an appointment is to blame for the delay. Access to Care Hawaiʻi Island |13

Providers believe appointment delays are more pronounced with specialists and, to a lesser extent, new primary care patients. Estimated wait times for appointments do not appear to be excessive, at least for existing patients, according to these Hawaiʻi Island health care professionals. More than two-thirds (68%) of established patients have appointments within five days. The wait times are considerably longer for new patients. Much fewer (42%) have an appointment within five days with nearly an equal number (39%) forced to wait at least two weeks or more for an appointment. ASKED OF PROVIDERS: For established patients/new patients, how long does it generally take to get an appointment? [PROVIDERS] 30%

2 days or less

43%

New patients

12%

3-5 days

25% 19%

1-2 weeks

15%

Existing patients

16%

2-3 weeks

6% 23%

3 weeks or more

11%

Though providers also report that the wait time to see a specialist is considerably longer with most choosing to refer patients to off-island specialists out of necessity. In fact, four in 10 (40%) believe the wait time to see any type of specialist is more than a month with almost two-thirds (63%) indicating the wait time is at least three weeks or longer. What is the typical patient waiting period for an appointment with a specialist? [PROVIDERS]

13%

< five days

13%

1-3 weeks

23%

3-4 weeks

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40%

>1 month

While the obvious preference is to refer to specialists on-island, 39% tend to go elsewhere. The main reasons for referring to off-island specialists are lack of specialty on island (74%), lack of specialty in referral network (59%) or the sense that appointment wait times will be too long (38%), because Hawaiʻi Island specialists are so overburdened here (37%). It is worth noting that nearly seven in 10 (68%) will refer to visiting specialists. The specialty areas called upon most for visiting doctors include orthopedics/orthopedic surgery (33%), cardiology (29%), endocrinology (22%), psychiatry/mental health counseling (22%), rheumatology (18%), nephrology (15%), oncology (15%), ENT (14%), dermatology (13%), urology (13%) and rehab such as PT, OT, and speech (13%). Unsurprisingly, these are the specialty areas that present the most difficulties for onisland referrals.

“Instead of flying patients to Oahu, should we be bringing doctors to Hawaiʻi instead?” - Hawaiʻi Island health care provider

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Needs and Solutions Professional Perspective: A Worsening Provider Shortage

“I originally planned to retire in 2012 but have been unable to find anyone I can refer my patients to.” - Hawaiʻi Island health care provider

Regrettably, Hawaiʻi Island health care professionals predict the provider shortage may worsen. Good numbers say they have contemplated a reduction in hours (49%), a mainland move (44%) or leaving medicine altogether (47%). Providers point to a long list of specialty medical needs they believe are in short supply and critical to improving community health: Mental health/counseling (76%) Psychiatry (70%) Endocrinology (50%) Dermatology (49%) Cardiology (48%) ENTs (46%) Nephrology (43%) Percentage of providers who in the past year have considered...

47% Retiring or leaving medicine

44% Moving to the mainland

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49% Reducing their hours

Aside from low reimbursement rates, many of the provider shortage Issues are bigger than health care, such as high cost of living, especially housing, and perceived isolation. Moreover, these experts believe the combination of our high cost of living (78%), low reimbursement rates (57%), housing crisis (50%) and the isolated nature of Hawaiʻi Island (48%) compound the ability to recruit new providers to their practice or organization. Loan repayment (27%), concerns about education quality on Hawaiʻi (26%), and the state’s General Excise Tax policy (24%) was raised by roughly one quarter with licensing (15%) and credentialing (15%) lower on the list.

“Working in Hawai‘i is challenging because of the significant pay cuts in comparison to the continent/rural communities, and the high cost of living. The biggest challenges have been the lack of infrastructural support for providers. I have never felt so hopeless as I have when I worked in Hawai‘i.”

What are the major obstacles to recruiting new providers to your practice/organization? [PROVIDERS}

- Hawaiʻi Island provider

78% High cost of living

50% Low reimbursement rates

Good numbers of providers identify three types of support needed in order to participate in workforce pipeline training: 1. Student housing (52%) 2. Ability to bill for precepting time (45%) 3. Expanding the preceptor tax credit (44%).

50% Lack of/cost of housing

48% Isolation of location

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Telehealth has expanded due to the pandemic, something providers hope to continue using. Prior to the pandemic, 40% of providers were using telehealth to treat patients. That number changed dramatically due to COVID-19, with nearly double the number of providers using it now (77%). Aside from adjustments to safety protocols (74%), increased use of telehealth was the most cited pandemic-related change to providers’ practices. Roughly one-third report making pandemic-related scheduling changes (34%) or developed new practice models (31%), both of which are less likely to be continued post-pandemic, according to respondents. Percentage of providers who...

40%

77%

78%

USED TELEHEALTH BEFORE THE COVID19 PANDEMIC

CURRENTLY USE TELEHEALTH

PLAN TO CONTINUE USING TELEHEALTH

However, like improved safety protocols, telehealth is a trend most would like to continue. The vast majority (78%) say they intend to use telehealth into the future. Virtual office visits (78%) are far and away the preferred use with virtual urgent care (19%) and “near-virtual” office visits (16%) lower on the list. Few intend to use telehealth for a referral to an online specialist (8%) or see its utility for virtual home health services (5%), though some focus group participants see the technological potential for patient monitoring. Telehealth can only be part of the current answer due to interest levels and stated concerns from the community. A digital divide is apparent here. Half (50%) of Island residents have used telehealth since the beginning of the pandemic and similar numbers (49%) vow to continue to use it. The frequency of needed of care impacts willingness to use telehealth. Those with higher needs are more inclined to opt for telehealth than those less likely to seek care. While there are no major differences by age, gender is a factor with women more likely to commit to telehealth than men. Educational attainment also influences willingness to Access to Care Hawaiʻi Island |18

participate in telehealth with highly educated Hawaiʻi Island residents more willing to use these platforms than high school graduates. Native Hawaiians and Filipino men are the ethnic/racial groups most reticent about telehealth. Type of insurance doesn’t seem to be a factor here. A good number of respondents (43%) report having “concerns” with telehealth. They cluster around perceived “quality of care” issues (65%) and lack of personal interaction (59%). Understanding and alleviating these concerns should be a high priority. In addition, a significant number of those who raise concerns about telehealth mention technology challenges, such as broadband connectivity (29%), lack of know-how (18%), discomfort with the video platform (17%) and/or lack of devices (16%). Another 17% mentioned having privacy concerns.

Most willing to use telehealth Has an advanced degree Chronic health issues (6+ visits) Younger college grads College grad + College-educated women Experienced health care delays Japanese under 55 years TOTAL

68% 65% 61% 59% 59% 58% 58% 49%

Most likely to say they won't use telehealth Sought care once or less in past year Native Hawaiian men Native Hawaiians 55+ years High school grad or less education Filipino men Native Hawaiians Older w/out college degrees TOTAL

65% 63% 63% 62% 58% 57% 57% 51%

There is a tension between increasing telehealth programs for those who seek care frequently and those who don’t. Shifting more high needs patients to telehealth and home monitoring could have the greatest impact on staff loads and the cost of care, and the health and wellbeing of more chronic patients. However, this is a white and welleducated group. Further data is needed from across the state to determine statewide telehealth usage and barriers. If these demographic patterns hold, prioritizing these ripe telehealth targets could mean furthering widening the digital divide, creating equity issues. The following groups require additional technology assistance in order to become successful telehealth patients – on top of assurances related to the quality of care and greater personal interaction.

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Technological obstacles to telehealth by key demographic groups

Groups most likely to raise concerns about….

Lack of broadband connectivity (29%)

Under 45 years; younger men; Native Hawaiians, especially women; Chinese; Older Filipinos; and Medicaid/Med-QUEST patients

Don’t know how to use technology (18%)

Believe language/culture are barriers to care; 55+ years, especially men; Native Hawaiians, especially older and men: Japanese, especially older and men; high school grads; Medicare patients; and Medicaid/Med-QUEST patients.

Privacy concerns (17%)

Frequent seekers of care; 45-64 years; women who are Filipino, Chinese or Native Hawaiian; younger Filipinos and Chinese residents; those with some college or vocational training;

Uncomfortable with video (17%)

Respondents 45-54; Native Hawaiians, especially women and older; Older Filipinos; Chinese women; and Kaiser Permanente patients.

Lack device necessary for telehealth (16%)

Native Hawaiians, especially older and women; older, non-college; and Medicaid/Med-QUEST patients.

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Checklist for Change (From survey findings and ideas offered by focus group participants who were largely providers) Many of the providers recognize the moment for positive change in health care delivery is now. To quote one provider, “We have opportunities for creating an abundance of positive change to improve health care quality and safety, raise employee engagement, and increase patient satisfaction and care.” Change and expand on community health Hawaiʻi Island residents and providers realize the life basics – housing, transportation, access to healthy, affordable foods – are critical to the health of the community. In fact, they are placed higher on the list by both groups than more “health specific” metrics such as access to exercise. These factors, chiefly housing, and cost of living, also make it difficult to recruit and retain physicians and other health care professionals here. The public and the health care experts also realize that health care delivery is complicated – more so than elsewhere. Our cultural diversity is an asset and a complicating factor that impacts many facets of health care delivery, especially because we are a multilingual society. They realize that health care needs, approaches and stigma are different across cultures and require an increase in cultural competency and language fluency, especially to the Hawaiian, Pacific Islander, and Filipino populations. As one provider put it, Hawaiʻi Island needs “a more relevant workforce that reflects the community through language, cultural competencies, cultural protocols.” The rural nature of Hawaiʻi Island also compounds some of the problems and, if not careful, could lead to greater health care inequity. Transportation to receive care is not easy for some – and many of these individuals lack the technology or know-how to seek telehealth, let alone reliable broadband. They offer up community support proposals to address these needs: Health coaches and day programs using professionals from different cultures to help to change behavior, learn life skills in the home (e.g., patients with Diabetes as well as addiction and depression). Create more advocates for minority populations inside health centers to create capacity and build more bridges to vulnerable populations.

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Deploy more multilingual teams to assist. Target men and those over 55 as they are the most likely to perceive language barriers. More career-building work and certifications in Hawaiʻi Island schools to build culturally competent, homegrown capacity. Provide more transportation options or care providers to the rural parts of the island (bus services, taxi coupons). Offer Hemodialysis, especially in rural areas (the only specific treatment method mentioned). Increase rural rotations, volunteer and other activities involving health care workers in the rural parts of the island to generate interest in serving outside of populated areas (Hilo). Prescription program for veggies, access to farmer’s markets, cooking classes for wellness, including cultural foods. Better information sharing on low-cost and free health services, using personal contact. Work to increase patient responsibility for their own health outcomes, understanding that policy and structural problems have contributed to this. Look at expanding coverage for culturally relevant healing practices not covered by insurance, and provide healing. One provider asked, “How might we look at Hawaiʻi Island being a place to harness this innovation?” Alternative appointment availabilities outside the normal workday, targeted to women, especially Hawaiian and Pacific Islanders and younger people. A note about equity. Continue to recognize the multidimensional and sometimes unmet needs of the Medicaid/MED-QUEST population. Throughout the survey, these were among the most consistently underserved. Same, too, with Native Hawaiians and Pacific Islanders. This is another finding that needs to be tested and confirmed statewide. Attempt to increase access to specialists among the Medicaid/MED-QUEST populations who suffer the longest wait times for appointments. Getting off-island is particularly hard for these populations, so consider bringing specialists to Hawaii Island to serve these patients. Look at increases in reimbursement rates and reform around GET taxes to further incentivize providers to treat these underserved patients. Consider innovative transportation options to help these underserved communities to get appointments. Provide instruction, broadband access, and devices to increase telehealth participation and comfort, including underserved rural populations where access to transportation is another impediment to receiving care.

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Expand cultural competency and language fluency efforts to reach more of the underserved who believe language and cultural barriers impact health care access. This is particularly important with Hawaiian and Pacific Islanders and Filipino men. Help those who qualify for assistance to enroll in health insurance programs. High percentages of Filipinos (66%), Chinese (65%) and Hawaiian/Pacific Islanders (62%) believe greater affordability is the most important factor impacting their health – much more so than access to care among these groups. Because these populations are among the most likely to work non-traditional hours, consider alternative appointment availabilities outside the normal workday. Keep in mind that meeting basic needs, especially around housing and access to healthy foods, impact health, wellbeing, and access to care. Staffing Shortages All agree that appointment delays, especially for specialists are untenable, and offisland travel for care is arduous and expensive. And given the number of providers contemplating moving to the mainland, or leaving medicine, it is only going to be worse. An existing shortage of Physician Assistants (PAs), nurses, Certified Nursing Assistants (CNAs), and Community Health Workers (CHWs) exacerbates these challenges in the healthcare system. Due to COVID-19 healthcare providers are burdened by a mental health crisis; and residents have postponed preventative care. Addressing housing and cost of living concerns will be critical to the future success of health care delivery. Medical experts remind us that the market is competitive nationally and health care professionals are in short supply. They offer up staffing and workforce proposals to address these needs: Improved salary model for physicians and other providers that considers the high cost of living and competition from the mainland job market. Housing for PAs, RNs, CNAs, CHWs, and others including students pursuing health care certifications and degrees. Recruit and train more Community Health Workers and make it a reimbursable insurance expense so providers and organizations can afford to employ them. More career-building work and certifications in Hawaiʻi Island schools. Residency incentives for those committed to staying in their community to work. Pursue home-grown talent and deploy providers to help mentor. “Providers are interested in bringing up the next generation.” Market and promote the benefits of rural caregiving (part of a close-knit community; greater opportunities for creative problem-solving;) Ability to bill for precepting time. Expanding the preceptor tax credit.

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Expansion of Loan Repayment beyond primary care to include specialists. Ask the question, “Instead of flying patients to Oahu, should we be bringing doctors to Hawaiʻi instead?” Mental health crisis Psychiatry and mental health counseling are, far and away, the two professional areas needed most, according to providers, though their list of needed specialists is long. They offer up proposals to address this growing crisis, while reminding us that basic needs such as housing are also critical to mental health and recovery. Train and deploy more Community Health Workers to help on a range of issues (houseless populations; kūpuna safety in the home; guidance through the health care and social service systems, including enrolling in insurance programs. Mental health prevention and awareness; practice cultural competency and work to reduce stigma; earlier intervention. Prioritize psychiatric needs because of the growing demand and its impact on entire family units, including the elderly. “It makes it difficult to be able to promote safety in the same building.” Address “systematic things like some clients needing to be incompetent or passed out in order to get help…Something preventive instead of allowing deterioration to happen.” Expansion of behavioral health programs in schools and school-based clinics. Telehealth and other alternatives to direct patient care Telehealth has grown significantly due to the pandemic and is something most providers want to continue using. However, the public is a bit more reticent because they connect the quality of care to face-to-face interactions. Additional factors that impact the utilization of telehealth include challenges accessing technology, a lack of comfort and know-how with the technology, as well as language and cultural barriers. The biggest telehealth users are patients with the most chronic needs, so moving more to this platform could help streamline the system, reduce costs, and provide access to those with less immediate needs to seek direct care. However, these individuals are disproportionately white, well-educated, and well-off. Further data is needed from across the state to determine statewide telehealth usage and barriers. If these demographic patterns hold, prioritizing these ripe telehealth targets could mean further widening the digital divide, creating equity issues. They offer up proposals to address this issue along with a summation of the groups in most need to technology assistance: Access to Care Hawaiʻi Island |24

Better understand quality of care concerns related to telehealth, one of the biggest barriers. It is related to another worry – lack of personal interaction and connection with the provider. Improve Wi-Fi, internet, and 5G services, especially in rural parts of the island. Increase remote patient monitoring efforts. More computer literacy coursework, access to computers. Tout gas savings and other transportation cost reductions with telehealth. Consider requiring insurance companies to cover the costs of telehealth (phone, internet) Better promotion of after-hours providers lines and other non-traditional ways to receive care. Policy changes regarding reimbursement rates, GET reforms and tax breaks Those suffering the most from the current system, especially when it comes to delayed health care and access to specialists are Medicare and Medicaid/Med-QUEST patients. Increasing reimbursement rates and addressing GET reforms are seen as vehicles for improving health care equity, not to mention physician retention and recruitment. Federal and state advocacy was mentioned a lot. “Possibly start a letter writing campaign.” Link low reimbursement rates to the state’s high cost of living to further demonstrate the hardship. “We are a high-cost state with low reimbursement rates.” GET exemptions were mentioned emphatically by some. “GET tax is odious. Hawaiʻi is the only state that taxes Medicare, Tri-Care and Medicaid patients.” Expand the preceptor tax credit. Collaboration, communication, and coordination It was requested that there be “navigational improvements” inside and out, between providers and networks and with patients. Some suggest that there is no one stepping up to do this, the ownership of the navigational elements is up for grabs. Better systems coordination from “high up level to the trenches.” New infrastructure: “Primary care delivery is pretty archaic on the island.” Divide up tasks and needs to create “Centers of Excellence” across the island. Encourage more referrals from ERs, give them a “stronger presence.” Re-think discharge planning and communications and its impact on those with mental illness and the providers who serve them. Better communication. Specifically noted: primary care to specialist; discharging entity to social services. Better overall care coordination, recognizing the good number of residents with complicated patient histories who haven’t seen a physician in years. Access to Care Hawaiʻi Island |25