Hawaii with the best access to health care?

Not according to those who live there:

A Commonwealth Fund survey said Hawaii has the best access to health care in the country, primarily because of a high number of residents with health insurance. But the study didn’t consider availability of doctors, Hawaii Medical Association members say.
“If we don’t have doctors available to see them, what good does insurance do you?” said HMA President Linda Rasmussen, a Kailua orthopedic surgeon. High malpractice premiums and low insurance reimbursements have created a “state of crisis” in Hawaii with physician shortages limiting access to health care, she said.

Comments

Anonymous
The way to deal with this problem is for the state to reverse certain aspects of the implementation of the Flexner Report. Allow for-profit medical schools and allow medical schools without coupling to large research institutions. Follow the California legal model and produce practitioners that won’t get comity to practice in other states. The state and the public need to have more of a say in the supply creation mechanism if they ever wish to control the rampant problem of patient abandonment and refusal on the part of providers to provide service to underserved areas.
Anonymous
Oh my, another state in “crisis”! However will we overcome?
Anonymous
CJD:
I don’t know how we will overcome, but I do know you won’t be part of the solution since all you ever do is make smarmy self-serving comments
Anonymous
You can be the first to let this group of physicians that weren’t smart enough to get into medical school in the first place take care of you and yours. Lots of quality candidates also would love to pay money to get a degree that they know would be useless in every other state in the country. Perfect way to entice the best and the brightest. Not to mention it is unconstitutional to restrict someone’s degree and livelyhood in such a manner.
Mike
anon 2:53… I’ve seen you make these same comments before and I never see any good responses to you, but I would just point to a couple of problems I see in what you suggest. Maybe they aren’t justified, so let me know what you think…
First, by uncoupling to large institutions, it sounds like many students wouldn’t see very good cases, or rare cases. You can’t just learn it all in a book. And many small places wouldn’t have every specialty required to metriculate through med school. For instance, some smaller places (and even some bigger ones) dont have Pediatrics. I certainly think every student would need such exposure. The small places may not be able to afford such a program, even the “for profit” ones. The big programs are prtected by federal funds.
Also, if my mother was sick, or some other reason I needed to move, are you suggesting I shouldnt be allowed to practice in another state? Even the Okie’s in the 30′s were allowed to travel to California for a better life. So I’m not sure what you mean about “comity”.
America is still a place where a doctor can put up a shingle if he wants. Are you suggesting that every one else can, but doctors cannot?
This is how I percieve your suggestions, but I may be off. Let me know your thoughts.
Anonymous
Mike, you’re absolutely right, it is still a place where a doctor can put up a shingle, charge whatever he wants, and work as much or as little as he wants.
The question is, why don’t more? Particularly given the level of complaining about what most of them do and how they’re paid for it?
Anonymous
I would have little problem in letting a provider that has passed the various steps of the USMLE and completed a residency provide care to me and my family. We already see this to some degree with foreign trained medical doctors that practice domestically (particularly here in California). Passing the board examinations and completing a residency are more of the gold standard (in my view) than admittance to a medical school when it comes to guaging the basic competency of an alloapthic healthcare provider.
Before the scope of the discussion gets mired, I will be the first to provide laudatory praise to the Flexner Report when it came to the adoption of the Johns Hopkins Medical Training model and the inclusion of a scientific basis for modern allopathic medicine. This being said, some of the other measures implemented were entirely anticompetitive. When it comes to the current training model, as everyone here knows, the first two years are basic science years that could be taught virtually anywhere by academically trained non-clinical faculty. The third and fourth years become a bit more demanding in terms of clinical requirements but there are numerous hospitals (non-research) that could serve as associated facilities for providing third and fourth year medical students with clinical experience. The subsequent issue becomes one of residency slots. Increasing the number of residency slots with placement and funding being provided by the state (instead of federally) for in-state students first would also be needed to remove the residency bottleneck. As far as the comity issue goes I would suggest looking at the California legal model (e.g. Ventura College of Law or Santa Barbara College of Law). California allows for profit law schools from which graduates are allowed the privilege of sitting for the California bar examination (one of the hardest in the country). Accreditation is handled at the state level without the guarantee of comity to practice in other states (such as an ABA accredited school). This model is perfectly constitutional as (no surprise) licensing boards in other states generally will not grant comity as it increases competition amongst legal providers in their own state.
I see little reason why states that are in “crisis” mode can not adopt a similar model for medical training. The state could even pay for all or most of the training knowing that they will have a sound investment in providers that can not leave the state if they wish to practice medicine. Considering this method of training would be a boon for states that have no medical schools and must rely on huge incentives to entice healthcare providers to even consider their state as a location for practice.
Increasing the supply of potential (key word here) healthcare providers by no means equates to easing the difficulty of the USMLE or cutting back on residency requirements. My suggestions, of course, do not include closing existing schools. The California legal model has not resulted in closures or loss of students from fine institutions such as UCLA, USC, Southwestern, etc. It has simply expanded the pool of lawyers that are out there competing for the services of the general populace.
Anonymous
” California allows for profit law schools from which graduates are allowed the privilege of sitting for the California bar examination (one of the hardest in the country). Accreditation is handled at the state level without the guarantee of comity to practice in other states (such as an ABA accredited school). “
Don’t forget that other level that those unaccredited school graduates have to pass prior to become licensed. What is, or was when I took it, called the “baby bar”. Not because it was easy, but because it wasn’t the real one.
As for “crisis”, the problem with it is that there is no objective definition. It’s just a scare tactic.
Anonymous
The baby bar is taken after the first year (I think or the second year). The students still have to take the actual bar exam at the conclusion of their JD studies.
Anonymous
“Allow for-profit medical schools”
They already “allow” that. There is a private DO medical school opening in Colorado next year.
“and allow medical schools without coupling to large research institutions.”
They already “allow” that too. 90% of osteopathic medical schools have no connection to a large research university.
So are you gonna come up with somethning new or just keep repeating the same shit over and over again thats already being used in this country.
Anonymous
Allopathic schools my friend. Not osteopathic schools. But you do bring up a good point. The osteopathic schools (for profit) produce competent clinicians, thereby serving as good basis for removing that component of the restriction (large research institution coupling) enacted by the utilization of the findings of the Flexner Report.
Anonymous
The only gateway to medical practive where there is any meaningful selection process going on is entrance to medical school.
People have to exercise a criminal level of negligience and incompetence to get canned from a residency and then can always find another. They all complete eventually as they are a source of cheap labor for the hospiitals.
Everyone passes liscensure exams eventually. Any imbecile can pass a test if he tries enough and preps enough. That doesn’t mean he actually has any sense or ability.
Boards are of some small use as a filter, but aren’t needed to practice and plenty practice without them.
None of that has anything to do with Hawaii. You could put a med school on every corner and still have the basic problem: a price regulated market that will not let the price adjust to economic realities in a high cost environment where the prices that the producer has to pay to live are in fact not regulated and are increasing. The inevitable result is a shortage of services.
Produce a million MD’s in Hawaii and the economics don’t change a bit. You may have more supply of MD’s but the capable will tend to melt off into greener pastures where there is more freedom to earn an income reglective of their ability. Any increase in supply will be accompanied by an decrease in quality.
The answer isn’t to beg for more reimbursement either. It is to cut loose from contracts that let others set fees. Every other business in Hawaii decides what it must charge to stay open and sets prices accordingly.
Anonymous
Uncoupling clinical work in medical school from the hospital work,that is contrary to the way many medical schools are organized right now, most having adopted a model of starting clinical applications and patient contact experience in the first year. You are advocating a return to an older, much more divided model.
As for allowing private, for-profit schools (and why they ought to be necessarily any better than any other model you’d have to explain), those seem to exist on nearly every English-speaking Caribbean island expressly for the purpose of supplying the U.S. practice market and so far, I don’t see that idea becoming anything other than a niche for applicants who are unable to gain admission to a U.S. mainland school. The whole idea of this kind of school smacks of the fly-by-night trade schools that look for “students” who can attend with their federally-guaranteed loan money, regardless of how well suited they are to medicine, academically or otherwise. If it were otherwise so compelling, where are the DeVry’s and University of Phoenix schools in this debate? My guess is that they already know medical schools are incredibly expensive money losers and not at all the kind of educational ventures a for-profit entity wants to go into. Law schools, in your example, are a poor comparison. Most nonprofit universities see their law schools as money-makers, since there is no large clinical or research enterprise required to support the educational mission.
Anonymous
Produce a million MD’s in Hawaii and the economics don’t change a bit. You may have more supply of MD’s but the capable will tend to melt off into greener pastures where there is more freedom to earn an income reglective of their ability. Any increase in supply will be accompanied by an decrease in quality.
One would have to implement all or most of what I have suggested for the totality to work. Schools that produced providers that were not granted comity to practice anywhere else but who had the bulk of their educational expenses paid for by the state would have no greener pasture to go to if they wished to practice. In regards to the last sentence, I would agree if there were did not exist a mechanism to test for competency. If there exists a problem with the boards/residency system regarding testing of competency then we should never see these two touted as being indicative of producing clinicians that by virtue of having passed the former and completed the rather can be deemed competent. I opt for the view that these two do give some measure of determination of competency and would be sufficient to weed out the chaff if such were allowed. The final question that we should ask ourselves is from the perspective of the currently unserved. If the choice is between a provider that is 85-90% of the “best” (using whatever metric that one chooses to use) or to go without care… what would one choose?
Anonymous
You are advocating a return to an older, much more divided model.
Not for all schools. Current schools can and should be left intact.
As for allowing private, for-profit schools (and why they ought to be necessarily any better than any other model you’d have to explain), those seem to exist on nearly every English-speaking Caribbean island expressly for the purpose of supplying the U.S. practice market and so far..
I am suggesting for-profit schools, specifically, because of the attention they were given by Flexner when he suggested that such schools be shut down. By allowing for-profit schools, the state need not invest infrastructure funds to establishing new schools. Instead such schools (and their incumbent cost) would be borne by the private sector. The state could instead focus its funds on paying for the education of students that would most likely (given the reception to the idea that I have seen here) only be allowed to practice in their state of training. I am not suggesting that such schools would be better than any other model, however they would reduce the capital outlay of state funds while providing states with a ready supply of potential providers that would justify the risk of spending money to train them. As far as the foreign schools go… students from such schools still need to pass the same requirements as domestic students (and they are held to a higher standard in regards to the USMLE). Either the licensing standards are an objective ubiquitous standard for determining competency or they are not. We can’t have it both ways in claiming that they serve as a standard for domestic students but do not serve as a standard for foreign trained students.
If it were otherwise so compelling, where are the DeVry’s and University of Phoenix schools in this debate?
They are precluded from the debate precisely by the mechanisms enacted in the Flexner Report. I would suggest that readers make the simple effort of reading the wikipedia entry on the Flexner Report. It provides the basics and readily provides the answer to this question.
Law schools, in your example, are a poor comparison. Most nonprofit universities see their law schools as money-makers, since there is no large clinical or research enterprise required to support the educational mission.
I see it to be a perfect example (particularly in the manner that I used it in regards to Ca-only accredited law schools). When it comes to states investing money for providers for a particular field, the risk of the provider fleeing the state is minimized if they can only practice in the state in which the investment was made. The issue here is not one of producing research clinicians but of producing clinicians to meet to the basic healthcare needs of the communities in question. Again, I am not in any way suggesting the current training model be changed for current schools. I am simply suggesting that it be supplemented. Our friend’s provision of osteopathic schools, which I have now co-opted, goes to show that such a non-research affiliated model is capable of producing competent clinicians.
Anonymous
Hawaii sounds like a great place to find another like minded FP and open up a cash only practice.
Anonymous
But that is a business risk and physicians tend to be risk avoiders. Where is the reward for the risk? There is an upper limit to what can be made practicing medicine ethically, and most people earn close to that whereever they are. One would have to really want to live in Hawaii to take that risk when they can enter a “usual” model practice in 90% of the rest of the country with a near certainly of doing as well or better relative to the cost of living without taking that risk.

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