Sunday, October 18, 2009

Could Hawai'i be generalized?

There is an article in this weekend’s NY Times that I found very interesting. It’s about the healthcare system in Hawaii – and how GOOD it is! The authors cite that Hawaiians live longer than any other state in the union and they they are generally healthier. The doubters among us say “no shit, Sherlock. It’s BEAUTIFUL all the time!!” However, there were some more intriguing tidbits in the article that made me wonder. Hawaii has the highest rate of breast cancer in the US, however, they have the fewest DEATHS from the disease of any state. Hawaii has the highest percentage of insured in the US and the lowest Medicare costs (possibly again contributable to that whole tropical paradise thing).

But really, the least number of uninsured? Massachuttess has the next lowest number of uninsured at 20%. Hawaii’s uninsured # is 10%. What’s going on? There is a law in Hawaii that every employee who works a minimum of 20 hours per week must have health insurance. Sure, there are people who try to circumvent the systems, employers making sure their employees only work 17 hours per week so that they don’t have to pay insurance, but generally the plans are cheap, no deductible, widely accepted and easily suffice for your average fairly healthy tropical paradise inhabitant.

I was puttering along this article until I hit the section where they start talking about the ERs in Hawaii. The author interviewed an ER doc who spends part of his year in LA and part in Hawaii. He described the Hawaii ER experience as “greased lightning.” Nationally, there are 400 ER visists/1,000 people annually. In Hawaii, that number is 200/1,000 people – half the national average. Again, you could make the tropical paradise argument, but Hawaii is not without its dangers. Anywhere there are highways, there are high-speed car wrecks. Just because the live in paradise doesn’t mean that Hawaiians don’t suffer from heart disease, asthma (highest rate in the US), COPD. Not to mention the kind of trouble the “touristas” can get themselves into with the vast number of adventurous activities available in Hawaii – there’s surfing, jellyfish, climbing, diving, parasailing, base jumping, heat stroke… all recipes for tourists ending up in the ER.

So why is this mystery ER doc saying that Hawaii’s ERs are “greased lightning”? The theory proposed by the article is that there is much better access to family care practitioners and general primary care docs, so patients go to their doctors for all the minor stuff rather than to the ER. i.e.—appropriate use of the primary care physician and the ER. This is something that I am continuously advocating as the root of our healthcare crisis—lack of access to primary care. I also always say that this is not going to be fixed without a massive expansion of our clinic system. The system as it is right now is at its breaking point on all fronts. This is the point at which Rob jumped into to play devil’s advocate.

What is the ratio of primary care physicians to population in Honolulu vs. NYC or Philadelphia? Barring that, what is the population difference? What kinds of numbers is each hospital on Hawaii serving in beds per population vs a NYC hospital? How many insured use the ER vs. primary care for minor complaints? How sick ARE these people in Hawaii (tropical paradise argument again)?

I’ll have to do more research and get back to those valid questions. For now, it appears that the spin on the NYTimes article agrees with my personal opinions – we need more primary care!

Hawaii’s system is not without problems. A number of the hospitals, especially on the outer islands, are failing. The rate of uninsured is increasing due to the current economy and the system is not built to handle the uninsured right now – it is a system built to handle almost 100% insured. It is interesting to wonder if the resources and the finances will be able to withstand what is to come. Also this whole “greased lightning” thing… I can’t see it. Maybe an entirely decompressed healthcare system works. I just don’t know.

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