Why Physicians Should Practice Medicine in Hawaii

September 27, 2013

Oncologist Linda W. Wilson and psychiatrist Jon Betwee share their likes and dislikes about practicing medicine in Hawaii.

Frequent windsurfing adventures in Maui led oncologist Linda W. Wilson, 64, to Hawaii. In the early 1980s, she was in a solo private practice in Los Angeles, but when the medical climate changed she began the transition to full-time medicine in the Aloha State, about two years ago.

She is currently the only medical oncologist at the Pacific Cancer Institute, specializing in breast cancer. She works part time, and nearing retirement, Wilson "sees all patients regardless of their insurance or financial status," she told Physicians Practice. There are three other radiation oncologists in her part of the Institute.

For you, what is the best part of practicing medicine in the state of Hawaii?

Practicing in Hawaii is perfect for me because I am able to do exactly what I want. By concentrating on breast cancer, I am able to focus my studies in one narrow field of oncology. I am also in charge of the educational oncology programs and CMEs that requires me to keep up with the oncology literature. And the Pacific Cancer Institute is a great place to work.

Other advantages are:

• There are unlimited numbers of patients and there is little or no competition amongst doctors to see them; there are more than enough patients and too few oncologists.

• There is very interesting pathology in Maui. In Los Angeles, for example, the rare cases are referred to oncology centers, so private doctors don’t really get to see them.

• There is no traffic to worry about and it takes just a few minutes to get to work, or go from hospital to office. This is in contrast to L.A. where the traffic prohibits efficiency in getting from place to place.

What, if anything, would you change about the climate for physicians in Hawaii?

My present contentment does not translate into a recommendation for practicing medicine in Hawaii. 

The major disadvantages are:

• Hawaii Medical Service Administration is the state-run insurance program which is difficult to deal with and reimbursements are low.

• The environment is not academic. Doctors don't keep up with the literature and it is difficult to get attendance at a journal club for oncology.

• Lots of turnover amongst doctors and staff. There have been five oncologists in Maui over the past four years; now there is only one main oncologist employed by the hospital and two other part-time oncologists including myself. The major subspecialty group closed their oncology service due to inability to keep a full time oncologist and inability to stay financially solvent.

• There are a limited number of subspecialists on the island and it is difficult to get patients in for appointments.

• It is expensive to live here, but Medicare reimbursements are structured on cost of living for the pacific islands in general and not based on similar cost of living areas like California or New York.

• There is no access to state of the art plastic surgery, breast reconstruction.

• There is no cross-coverage available since so few oncologists and other specialists.

• Although Honolulu offers some services not available on Maui (like PET scans), there is no state of the art oncology there compared with the mainland.

(read psychiatrist Jon Betwee's take on Hawaii on the next page)

The sun and the surf of central Maui have always appealed to psychiatrist Jon Betwee, 70, but he knows that year-round life in Hawaii doesn't appeal to every physician.

"Living here is not like vacationing here," said Betwee, who has practiced in theAloha State for 38 years. "It's not for everybody."

And that seems to be the case for physicians especially as Betwee prepares for retirement. Finding a physician to take his patient base has not been easy as recruiting peers to Hawaii has proved difficult.

For you, what is the best part of practicing medicine in the state of Hawaii?

The best part of practicing in Hawaii is living here. This is a great place to live.

Hawaii is an unusual atmosphere. A few years ago, we had almost universal healthcare coverage, with a combination of commercial coverage, Medicaid, and gap group coverage. The gap group disappeared and we now have privatized Medicaid into individual HMOs, which works much better than standard Medicaid. I don't know if it's any cheaper, but it certainly works much better for everybody.

We've had a state law since 1974 requiring employers to offer medical insurance for anyone working more than 19 hours a week. And the formula for how that is funded is very specific. Unfortunately, it falls very heavily on the employer. The formula has never been altered since 1974; it really should be so that employees are required to contribute more. It's a burden on business and this is a state of small businesses, but it works.  I think for the general good.

The insurance scene in Hawaii is dominated by [the Blue Cross Blue Shield-run Hawaii Medical Service Association (HMSA)]; there are three much smaller, locally based companies. That's both good and bad. It's good in that it makes things much simpler. It's not so good because they have a monopoly and can essentially set the terms. But they are supportive of private practice.

In other states, large companies will offer medical insurance to attract and retain valued employees. In Hawaii, it is enacted for everybody, no matter how many employees you have. It is remarkably similar to Obamacare.

What, if anything, would you change about the climate for physicians in Hawaii?

The disadvantage for physicians is because of the virtually universal participation with this Blue Cross company, fees are low. You are not required to participate, but it is very difficult, because the population, immediately in hearing you are not a participant, will look elsewhere [for a provider]. I don't know how many people don't participate, but it is a very small number. 

So low fees are a downside. Other than that, part of the insurance law requires prompt payment, which is adhered to, so there are pluses and minuses.

We are losing physicians here, so access to medical care on Maui, as well as the other neighbor islands, has become pretty difficult. I'm about to retire and I'm looking to distribute patients among other people in the community. I have somewhere around 40 Medicare patients and there are no other psychiatrists willing to see them, so I don't know what's going to happen to them.

I've tried to recruit somebody to replace me and I can't do it. The cost of living is too high, the reimbursement too low, schools are problematic - no one wants to be in practice anymore. They all want to be employees of some sort.

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