Hawaii Medical Association director eager to reduce health care costs but has no easy solutions

Dr. Chris Flanders is a smart guy — a neuropathologist who also is executive director of the 1,100-member Hawaii Medical Association (HMA), based in Makiki — but sometimes, like when he’s talking about homelessness and the medical quandaries it presents, he wishes he were smarter.

“I know that there are some volunteer programs that are going on to try to deal with that (the medical needs of the homeless),” Flanders said last week. “The medical students at JABSOM (the University of Hawaii John A. Burns School of Medicine), they’ve kind of taken that program under their wing; they go out and take a look at the homeless folks who are down in Kakaako around the campus. But that’s a tough problem. I just wish I was smarter and knew the answer.”

On other issues affecting Hawaii’s doctors — such as physician-assisted suicide, the privatization of Hawaii’s state hospitals, how to control medical costs and Hawaii Medical Service Association’s (HMSA) shifting policy on pre-authorization of medical tests, among others — Flanders, 60, speaks with greater certainty, often in testimony at the state Legislature.

At the helm of HMA since December 2010, Flanders is a graduate of Ainsworth High School in Flint, Mich. He then earned a bachelor’s degree in political science from the University of Michigan, a bachelor’s in biology from the University of Detroit, and a medical degree from Des Moines University. A residency and fellowship followed at the University of Texas Health Science Center at San Antonio, where he practiced until moving to Hawaii in 2008 to be with his wife, Jone, a cardiologist who had moved here in 2007 to set up a since-closed cardiology center in Waimea, Hawaii island, and now works at Tripler Army Medical Center on Oahu.

The couple have three adult children and live part-time in Waikoloa, also on Hawaii island.

“I fly back and forth on the weekends,” he said. “I love it there. I’d like to figure out a way to get back. I’m trying to get the medical association to move there, but I’m not getting any support.”

Question: One of the benefits HMA offers its members is legislative advocacy. What kinds of measures did you support or oppose in the latest legislative session?

Answer: Yeah, that’s a big part of what we do, advocacy work. This last legislative session we had a couple of things.

There was a bill having to do with the prior-authorization, called “relating to liability.” It was a bill that would have passed some of the liability for bad outcomes caused by delays in the prior authorization (of medical tests ordered by doctors for patients insured by the Hawaii Medical Service Association). That was a big one. We were in support of that, but unfortunately that died in conference.

There also was a psychologist prescriptive-authority bill. That was another big one, and of course we opposed that. It would have allowed psychologists to be able to prescribe medications. We opposed that one and it didn’t pass.

There were a couple of bills that had to do with physician discipline, and they were related, actually, to the recent Star-Advertiser reports about physicians who’d gotten in trouble in other states and were able to continue practicing in Hawaii. So we supported a couple of bills to allow for the disciplinary board to take quick action on those whose licenses had been suspended in another state. That only makes sense, in my mind.

Q: HMA President Scott McCaffrey recently called on HMSA to initiate a moratorium on its imaging pre-authorization program. What’s the status of that now?

A: They have not undergone a moratorium on this. We’ve met several times and are continuing to meet.

The concern about this is the way things were handled. It kind of came out of nowhere. The doctors were taken by surprise.

Traditionally it’s been that when these imaging studies were ordered, the order was followed through. It was carried out and was paid for, and most of the doctors received a waiver. … But what HMSA did on Dec. 1 was it cancelled all these waivers, so everybody had to go through the prior authorization. And that was a problem.

So neurologists who as part of their normal, everyday practice might order MRIs or CAT scans, or orthopedic surgeons who were used to ordering CTs or MRIs, to look at skeletal deformities or whatever it might be, all of a sudden now had to go through this process that in some cases took days or even weeks to resolve, and patients weren’t happy with it. The doctors certainly weren’t happy with it, so that’s something we’ve been trying to work out.

Q: What do you think is the time frame for resolving this?

A: Well, HMSA has just set up a physician advisory committee or board to discuss this issue. … We’ve got a couple of members on there, and I’ve been invited to attend. So the conversation will continue.

Q: What’s your view about the privatization of the state’s hospitals, like on Maui and elsewhere, and what do you think about how that’s been proceeding?

A: I think we need to do something to improve the state of those hospitals.

Like I said, I live on the Big Island, so it’s either North Hawaii or the Kona hospital, and really they haven’t been kept up to the standards of what we would expect for our hospitals. The infrastructure is just not there, and that hurts the neighbor islands, not with just a lower expectation of receiving care at the hospitals, but also it hurts us with recruitment and retention of our physicians.

When you’re trying to bring somebody in from the mainland, for example, they come out, they’re enchanted by the idea of practicing in Hawaii, obviously, and then they come into Hilo or Kona, for example. If they’re cardiologists, there’re no cardiologists in Kona who go to the hospital. There’s no CAT lab. There’s none of what cardiologists think of as being the standard of care for a cardiologist. Those things just don’t exist, so there’s no interest there.

Q: Do you think the legislative measure to give union members at those Maui hospitals being privatized those very expensive severance packages will discourage future privatization efforts?

A: I don’t know. I haven’t really been tracking that part of it too much. That’s a corporate issue. I’m mostly looking at the health care part of it.

Q: What do you think should take place for the Wahiawa hospital? It seems to be on the dole and it’s not even a state hospital.

A: Yeah, that’s another issue. If you will recall when the nation was going through the Affordable Care Act, there were discussions that we would probably see closures of hospitals, that not all the hospitals that are in place now would be able to get through this transition and some would close their doors. I think what we need to look at from a public standpoint is not individual hospitals closing up but health care being closed to geographic areas, and take a look at what the impact is if a hospital were to close, and act on that.

Q: Speaking of the Affordable Care Act, how’s that been workin’ for ya? Is it much different from when Hawaii had its own government-mandated health care system?

A: For the most part Hawaii’s Prepaid Health Care Act has remained intact. Maybe the question is: Is the Prepaid Health Care Act sufficient to get a waiver on implementing some of the requirements of the Affordable Care Act? And I think there’s some conversation taking place about that.

Q: What kind of waivers do people want?

A: I think some of the requirements of the Affordable Care Act are being taken care of by the Prepaid Health Care Act already. The insurance mandates (of the Hawaii law) went a long way such that the number of residents we have here who have health care insurance is sky high compared to most of the nation. That part is already in place, so to reorganize for the purpose of complying with the Affordable Care Act, that just really doesn’t make any sense.

Q: Around the time Obamacare was being approved, HMA said it was concerned about its provisions as they might relate to “medical liability reform, commissions and committees that lead to limiting medical innovation, lack of provisions ensuring universal access, and factors that increase overall costs.” How has that played out?

A: Well, I think part of those have come about. All the increased regulation has certainly increased the cost of practicing medicine for the physicians, and also the costs of premiums for our patients. Those kinds of things continue to bother us.

Q: Those were supposed to go away, right?

A: You know, we have to ask ourselves: Is the return on investment worth it when we make these changes? There are charts that have been made that show the increase of physicians over time and the increase of administrators over time, and the administrative line is very steep, and that’s where the cost of medicine in large part is taking place. Physicians seem to be in everybody’s crosshairs when they talk about lowering the cost of health care, but we’re only — well, depending on what studies you look at — between 10 and 16 percent of the total spent on health care. That’s all that goes to physicians.

Q: Do you have any suggestions about how to lower medical costs?

A: Gosh … You know, it’s tough, because health care really has become a high-tech industry, so there are a lot of the things that we do that we couldn’t do 20 years ago. When I started my career, MRIs didn’t even exist. We used CAT scans, and before that, X-rays. In neurosurgery, it wasn’t too long ago they were locating brain tumors by external exams. So if the patient couldn’t move their left hand and had decreased feeling in their left forearm, they would locate it to a specific region of the brain and they just went into surgery blind. Thank God we don’t have to do that anymore.

But the flip side of that coin is technology comes with a cost. It’s not cheap to purchase the equipment, and it’s not cheap to develop it.

I think what we need to do is answer some of the questions as to what the drivers of what the health care costs are. And my feeling, like I said earlier, is that we, the physicians, are just 10-16 percent of the cost of health care, so that leaves 80-85 percent unaccounted for.

You know, everybody’s complaining about prescription drugs. Well, why do prescriptions drugs cost more in the United States than they do in Canada and Mexico and Europe? I think we need to come to terms with those kinds of things.

Q: Is it true many doctors are turning away Medicare or Medicaid patients?

A: Well, the programs are all voluntary from a physician’s standpoint, but we do it because we can take care of patients; we want patients to get help. … But that being said, what we need to remember about the health care system is it still is a private system. So the doctors need to be able to keep their office doors open in order to be able to provide health care to their patients. That means they have the electrical bills that everybody else has, they have the other costs that everybody else has, so here in Hawaii it becomes a challenge.

Medicaid pays about half of what Medicare pays for an office visit, and Medicare pays maybe, I don’t know, maybe 80 percent of what HMSA pays, so there’s a financial balance that needs to be struck, that if you fill your office with nothing but Medicaid patients, that’s not going to pay the bills. So you have to balance how many Medicaid patients, how many Medicare patients and how many private insurance patients. That’s the business part of it.

Q: In 2012, HMA said it opposed physician-assisted suicide, because it would be “unethical and fundamentally inconsistent with the pledge all physicians take to devote themselves to healing and life.” Is that still the position of the association?

A: We’ve softened our position on that quite a bit. Part of that is that the hospice programs and palliative care have really advanced quite a bit, even since 2012 when we said those things, that for the most part patients who are terminally ill are able to get into those programs, and they really do an excellent job at controlling pain and helping ease the transition, for both the patients and the families, which you probably could make as big a case for the patients’ families as the patients.

Q: Did you agree with that group locally (Compassion and Choices) that said Hawaii law already actually allows physician-assisted suicide, that it’s sort of implied in the way the law was written?

A: You know, I don’t really buy into that. The attorney general came out with his opinion that he didn’t really interpret the statute that way, so I think it’s still that physicians aren’t supposed to help, but I think the important thing is that even though maybe we can’t directly help that we don’t get in the way of the transition. I think that has become — I don’t want to say standard of care — but I think generally more accepted than it was five years ago.