January 27, 2020


Hawaii Medical Education Council
Monday, January 27, 2020
7:30-9:00 am

                                    John A. Burns School of Medicine                                                                                                   Kaka`ako Campus                                                                                       651 Ilalo Street, Medical Education Building                       Room 202

Parking – Please park in the Gold Bond Building across the street, we will validate. See map below for directions.


                            Hawai‘i Medical Education Council (HMEC)

              University of Hawai‘i, John A. Burns School of Medicine                                 Date: Monday, January 27, 2020, 7:30 a.m. – 9:00 a.m. Location:  651 Ilalo Street, Kaka‘ako Campus, Medical Education Building,  Room 202, Honolulu, Hawaii 96813

  1.    Review & Approval of October 28, 2019 Minutes –Dr. Hedges (distributed via email to members on 1/26/20)
  2. Report from HMEC Chair – Dr. Hedges                                                                a. Announcements (5 minutes)                                                                              b. Update on Legislative Strategies – Jerris Hedges and Cynthia Nakamura (15 minutes)
  3. Physician Workforce Data Updates & Synergies – Aimee Grace & Kelley Withy (40 minutes)                                                                                             a.  Physician Workforce                                                                                               b.  Physician Recruiter                                                                                                 c.  Preceptor Tax Credit Update from 2019                                                   d.  Synergies
  4.   HMEC Recommendations to the 2020 Legislature – Lee Buenconsejo-Lum (20 minutes)

  • Physician Workforce Data Updates & Synergies – Aimee Grace & Kelley Withy (40 minutes)
    1. Physician Workforce 
    2. Physician Recruiter 
    3. Preceptor Tax Credit Update from 2019 
    4. Synergies
  1. HMEC Recommendations to the 2020 Legislature – Lee Buenconsejo-Lum (20 minutes)

RECOMMENDATION #1                                                                                        UH/HMEC recommends that the 2020 State Legislature and State Executive Branch continue to support and provide a State match to continue the Hawaii State Loan Repayment Program.  Ideally, this match could be provided as a supplement to the annual Department of Health (DOH) budget with the explicit instruction for the DOH to annually transfer those funds to JABSOM as long as JABSOM oversees the health professional loan program for Hawaii – including coordination of the National Loan Repayment Program Federal match.

RECOMMENDATION #2                                                                                      UH/HMEC recommends that the 2020 State Legislature and State Executive Branch support the expansion of JABSOM faculty and staff to provide satellite educational programs for year-round undergraduate medical education on Hawaii and Maui Islands which will allow expansion of the medical school class size with more neighbor island medical education, and will allow exploration of residency training expansion to these islands. 

RECOMMENDATION #3                                                                                  UH/HMEC recommends that the 2020 State Department of Human Services and other stakeholders explore the mechanisms to obtain Federal Medicaid GME funding since many of the residency programs provide inpatient and ambulatory care for Medicaid populations.

5.  Additional Items                                                                                                                  a.  Announcements – Next HMEC Meeting – Monday, April 27, 2020 @ 7:30am in MEB 202

6.  Adjournment


                          Hawaii Medical Education Council (HMEC) Meeting                                              January 27, 2020  Time:  7:30-9:00 a.m.                                                        John A. Burns School of Medicine, Room MEB 202                                                    651 Ilalo Street, Medical Education Building,                                        Honolulu, Hawaii 96813

1.       Review of Minutes Minutes from our last meeting, held on 4/29/19, were reviewed and approved. Motion to approve came from L. Shapiro and second by J. A. Otsuki. Motion to approve without changes carried unanimously. No opposed and no abstentions.NA.
2.       Chair Report a.       Announcements: NA.
Dean J. HedgesDean Hedges acknowledged and welcomed special guest, Dr. Josh Green, Lieutenant Governor of the State of Hawaii, and completed introductions around the room including those joining via Zoom.
The National Medical Association (NMA) is in town and honors Hawaii by holding their convention in Honolulu every 4-5 years. JABSOM has previously participated in the meeting and will be providing several sessions this year over the course of the 4-day conference.
Additional visiting dignitaries and related recognition include the following: The United States Surgeon General also will be visiting Hawaii to participate in the NMA, and has visits planned for the VA and JABSOM in addition to visits on the neighbor island, such as Molokai. Rear Admiral Louis Tripoli and a large contingent from US INDOPACOM, US Federal Government and partners from across the UH System and East-West Center will be visiting JABSOM to have a roundtable discussion on improving the health systems in Oceania. The United States Secretary of Veterans Affairs will be visiting Hawaii to assess the status and changes of the recent implementation of the MISSION Act for our VA offices. Dr. Griffin Rogers, Director of the National Institute of Diabetes and Digestive and Kidney Diseases who will nationally recognize and honor Dr. George Hui for the STEP-UP (Short-Term Research Experience for Underrepresented Persons) program for the Pacific that extends research training opportunities to rural students in Hawaii and the Pacific Islands.
b.       Legislative strategies update for 2019 (Dr. Buenconsejo-Lum for Cynthia Nakamura):
Bills Passed In 2019:
Act 262 (SB1404): Relating to Loan Repayment for Health Care Professionals was signed into law on July 5, 2019. This will provide $150,000 in funding for FY 2019-2020 and is the third year the State of Hawaii has supported the match of federal funds. As this program has been successfully administered through the Department of Health (DOH) to JABSOM, the long-term goal is to attain an annual state match of $400K (this is the maximum amount the federal government will match) built into the DOH’s budget infrastructure as a standing item. This would eliminate the need to seek legislative approval to renew funds every 2 years. The program is currently assessing the number of awards that can be issued this year based on current available funds.
In a related matter, thanks to tremendous efforts by Dr. Kelley Withy and her team, JABSOM has been able to work with donors to develop a tuition repayment program (similar to a scholarship program with payback services) using a similar mechanism as the loan repayment program.
Act 32 (SB 1033): Licensing of midwives was signed into law on April 30, 2019. Our Maternal-Fetal-Medicine program, a division of Obstetrics-Gynecology, played a huge role in pursing this Act to reduce infant mortality. Act 32 acknowledges additional requirements and provides regulations needed to ensure safe practicing of midwives.
Act 139 (SB 1246): Relating to telehealth was signed into law on June 28, 2019. It establishes goals for the adoption and proliferation of telehealth to increase access to care. Varying initiatives are being pursued as this will be part of the future of medicine. JABSOM will continue efforts and build on partnerships with the VA, TAMC and our hospitals to build a telehealth network for Hawaii.
Act 140 (HB1453): Relating to emergency medical services (EMS) was approved on June 25, 2019. Authorizes the DOH to establish fees for ground transportation to medical facilities other than acute care hospital emergency departments and for provision of emergency medical services that do not include transport. Authorizes Medicaid programs to provide coverage for health care provided by emergency medical services personnel. Lieutenant Governor Green commented on the importance of getting these services right as it will help guide more cost efficient EMS and will help to develop outreach to alternative health sites for less acute needs.
Act 181 (SB 1406): Relating to Physician Assistants (PAs) was signed into law on July 2, 2019. Allows supervision of PAs by a group of physicians; permits supervising physician or group of physicians to establish policies regarding records review. The originally proposed bill would have created another pathway to independent practice which caused concerns for how PAs would be reviewed and monitored. Act 181 incorporated revisions which allow continued supervised practice while expanding the format where supervision could occur which helps make supervision more manageable.
Act 182 (SB804): Relating to Palliative Care was signed into law on July 2, 2019. Establishes 2 culturally competent palliative care pilot programs within the Department of Health to promote palliative care. This is important because it ties into the work we have been doing to improve the overall capacity for having vital conversations about end of life and goals of care. It is important to be able to facilitate the conversations as the medical-aid-in-dying was signed into law in January 2019. We are looking at a program called, Vital Talk, that could provide training and a model that is customizable. In Hawaii this could be initially focused on geriatrics (original program designed for Oncology) and expand to include nursing and social work as part of the interdisciplinary team. JABSOM, in conjunction with DOH, will be planning to submit applications for palliative care pilots. The initial idea would be to have trainers on every island and work closely with the hospitals for additional support.
Act 251 (HB 673): Relating to The Electronic Prescription Accountability System was signed on July 5, 2019. Specifies that a health care provider shall not be required to consult the electronic prescription accountability system for patients when the prescription will be directly administered under the supervision of a health care provider, provided that the system is consulted when the patients are initially admitted at a hospital, for patients in post-operative care with a prescription limited to a three-day supply, or for patients with a terminal disease receiving hospice or other palliative care. This Act was edited and done in response to the initial implementation which posed significant issues, was time-consuming, challenging to check, and now provides clarification for providers.
3.       Physician Workforce Data UpdatesDr. Withy shared handouts depicting recipients as of 8/1/2019 of the loan repayment program. 20 graduates (2 non-federal funding), 22 actively serving (2 non-federal funding), 3 requested for deferments and 1 defaulted. Of these 20 graduates, 55% are working in underserved areas, 8 (40%) working in their original service sites, and 7 (35%) working in Health Professional Shortage Areas (HPSAs) which is 10% higher than the national average. The program will likely give out 4 more loan contracts this year. Last year 8 requested applications went unfunded. Average loans ranged from $35-50K with the program starting with the largest debt then works down. Recipients are advised to always pay their minimums as the program cannot pay late fees and consolidate debts using “educational Loan” mechanisms. The loan repayment program is not allowed to pay for personal items (i.e. car, house, etc.). Average overall debt for physicians is $250-$350K. Ongoing updates to be provided by Dr. Withy and Dr. Grace.
Kelley Withy + Aimee Grace
The UHealthy Hawaii initiative (flyer shared) was created to improve health and health care in Hawaii and the Pacific by leveraging the UH System’s health science programs and creating collaborative partnerships. The four major areas of focus include: 1. Ensure a robust statewide health workforce, 2. Discover and innovate to improve and extend lives, 3. Promote healthier families and communities, and 4. Advance health in all policies. Next meeting we will see a list of those that have done all their training at UH.
Dr. Grace began her presentation with a PowerPoint that showed the vacancies for varying types of health professionals in addition to physicians. Dr. Withy and the Council discussed workforce needs based on the national projections. We will be short 800 physicians though we only have 300 job openings posted by employers of physicians. Compared to the mainland positions and numbers, we may not need the 800 physicians (in Hawaii), but certainly will need more than the 300 positions posted – given that independent practices would not be reflected in employed physician position needs. The traditional model of physicians opening a practice and employing 10 people is no longer being sustained and some practices are closing due to payment transformation, new practice requirements and retirement. To help, private practices may use the AHEC as a recruitment resource and are able to post positions on their website. Last month there were 288 physician job postings through AHEC.
Dr. Grace continued and informed the Council that she is working with Representative Mizuno and Senator Baker for the upcoming “Hawaii's Health Workforce Development for the 21st Century” legislative informational briefing to be held on August 21, 2019. Goals of the briefing are to seek community input into top priorities for comprehensively addressing Hawaii’s health workforce challenges, draft legislation to reflect these priorities, work to address any needed administrative changes, and ensure robust community stakeholder engagement. Invitees include all community members, key community stakeholders such as health care systems and health care organizations along with the press. Key leaders that are expected to attend include: Representative John Mizuno, Senator Roz Baker, Majority Leader Della Au Belatti, Lieutenant Governor Josh Green, Director of Health Bruce Anderson, University of Hawaii President David Lassner, Dean Jerris Hedges from JABSOM and Dean Mary Boland from Nursing. The draft agenda includes the national landscape on health workforce and will focus on potential solutions to workforce challenges in each of the following areas: entry-level health professions, nursing, physicians, social work, public health, optimizing Hawaii’s health workforce, and other shared workforce challenges.
Potential solutions to address physician workforce shortages (presented by Dr. Withy):
1.       Rural Training Hub. Neighbor island medical student training site to be used throughout the 4 years of training. This would include PBL training, pre-clinical and clinical training, etc. Maui needs space and faculty in order to expand training there. After a dedicated faculty group for medical student education has been established, routine rotation experiences for residents also can be explored. Maui Memorial has a visiting nurse’s quarters that could be a potential housing option now that more local nurses are being training on island. A similar model could be developed for Hilo and Kauai islands. Opportunities include engaging with Kaiser to attain possible support and partnering with local practices to build a preceptor cohort. Dr. Hixon recommended reaching out to Drs. Colleen Inouye and Frank Baum who are part of the Hawaii Independent Physicians Association (IPA) as possible resources for future resident rotations and possible housing arrangements.
2.       Payment Reform Working Group to bring everyone into the discussion to address the needs. Include providers, insurers, and legislators to improve satisfaction with payment reform and address potential Medicare reimbursement changes, Quest reimbursement, and rural payment differential.
3.       Tuition Relief with Service Payback could lead to potential expansion and adjustment of scholarships provided by private donors. JABSOM has 19 full scholarships this year (out of 77 students), 14 of them require practice in Hawaii after graduation. It could be years before we close the physician gap - even further increase in class sizes. In-state tuition for out of state students is a way to get a 4-year commitment to stay in Hawaii after training and hopefully longer. Could be a good time to renew discussions with community health hospitals investing in a condo to help subsidize housing while in training to help offset the financial burden and make living and training in Hawaii more attractive.
4.       Physician Recruitment Expert needed to help with recruitment and retention efforts. The ideal candidate for this should have time and an energetic personality to help be a resource for others. This effort could include coordinated efforts with local recruitment groups to help create a website and flyer inclusive of opportunities and everything you need to know about practicing in Hawaii. Dr. Hixon recommended providing these tools as an app for easy use by the next generation of providers.
Potential Solutions to Optimize Hawaii’s Health System (presented by Dr. Grace):
1. Better Utilization of Pharmacists and improved integration as part of the healthcare team. Will need to investigate further how this can be supported, explore billing options (e.g., HMSA) and take a closer look at the VA, Hilo and Kaiser models that currently incorporate this. The Family Medicine Residency Program was built on a system of co-learning and has been integrating team-based care for the last 7 years. Better utilization would improve patient outcomes (better rates of diabetes and hypertension control) and free up physicians to see more patients. The AlohaCare Waiwai Ola grant awarded $250,000 to the UH Hilo Daniel K. Inouye College of Pharmacy to expand ambulatory pharmacy care on Hawaii Island for their patients. Opportunity to expand to tele-pharmacy as the VA currently does.Dr. Withy to reach out to Drs. Inouye and Baum.
2. Expansion of Telehealth. Telehealth can increase access to care, decrease costs, and improve quality of care. Goal is to align and be consistent with the DOH’s telehealth strategic plan to maximize our efforts. Additional support is needed to provide training, recruitment and retention. Training of health sciences students and the development of telehealth curriculum is part of the future of medicine. Other strategies include improving broadband access, licensing, policy alignment (with provider education), and reimbursement strategies.
3. Expand the Hawaii Interprofessional Education & Training (HIPE) working group efforts. UH West Oahu is interested in creating a “Multi-Disciplinary Clinical Training Center” to provide clinical training opportunities for students and clinical services for Oahu’s residents (i.e., respiratory care and dental hygiene). Recommend referring to this as the “Interprofessional…Center.” Faculty will be needed.
4. Expand Community Paramedicine – further discussions needed. This could be an opportunity for interprofessional training.
5. Support Collaborative Care Model – further discussion needed. Cautioned to be careful and very clear with the nomenclature as there are various models referred to “collaborative care” and the Health Resources and Services Administration (HRSA) can be very specific.
6. Expand Use of Social Workers – deferred till next discussion.
Next Steps:Dean Hedges to consider timing to renew discussions of an investment condo.
We will continue working on a system level to encourage and support legislation for the UHealthy Hawaii program initiative and engage in further discussions for the potential of building a neighbor island training hub. To address the social determinants of health, it could be in the best interest of UH to learn more about the World Health Organization’s (WHO) Health in All Policies model that many around the world are adopting and would address the fourth strategy for the UHealthy program to “advance health in all policies”. Discussed concerns that contribute to social determinants of health such as poverty, education, transportation, paying for ancillary services, and food security to see if there could be opportunities to leverage UH system school resources in these areas (i.e. culinary school).
4.       HMECDetails for recommendations for 2019 and 2020 to be discussed at our next meeting. Further discussion needed with Judy Mohr Peterson to follow up on any modifications needed for Medicaid. Dr. Buenconsejo-Lum will continue to seek input from HMEC members and provide updates at future meetings.
Recommendations to 2019 and 2020
L. Buenconsejo-Lum2019 RECOMMENDATION #1 - UH JABSOM/HMEC recommends that the 2019 State Legislature assess the advisability and feasibility of an annual and recurring GME Appropriation to support HMEC-designated residency/fellowship programs with a particular emphasis on primary care.
• HB609 introduced by Representative Ward, was referred to 3 committees for review. This bill which appropriates monies to the GME program for residency programs in Hawaii, provided that the funds are matched dollar-for-dollar by private sector medical hospitals and institution, has been heard but has not been assigned a hearing yet. This bill would appropriate money to JABSOM through the DOH. Current plan is to investigate other factors driving costs to see if those factors/costs can be reduced to allow more funding to be appropriated for educational commitments (SB1400). A noted challenge is that these bills, if successful, would only be for 1-2 year legislative commitments. This might help with planning, but would be problematic for ensuring continuity of GME funding.
2019 RECOMMENDATION #2 - UH/HMEC recommends that the 2019 State Legislature and State Executive Branch support the State Department of Human Services and UH JABSOM to work together to develop a State Medicaid GME-focused Matching program to augment GME faculty and resident/fellow funding.
·   Reviewed HB1444 proposed activities which includes this HMEC recommendation (#2) though there is no current bill referral scheduled. The HMEC also reviewed the list of participants outlined in this bill for collaborative efforts noting the timeline is very specific with no appropriations tied to the bill. This bill, written and introduced by Representative Belatti, establishes a Primary Care Payment Reform Collaborative task force in the DOH to examine issues related to primary care spending and data collection and to develop recommendations to the legislature. The report shall include payment reform; value-based care; workforce and recruitment; directing resources to support and expand primary care access; increasing integrated care including for women’s and behavioral health; determination of the current percentage of medical expenses in the State allocated to primary care; primary care spending mandates in other states, including an assessment of methods for establishing a minimum primary care spending percentage or dollar amount; data collection issues regarding primary care spending in the State and its potential impact on data submitted to Hawaii’s All Payer Claims Database; and potential standard definitions of “primary care “ that may be used in future legislation. If passed, the timeline for the task force to complete its work is less than 1 year (before the 2020 session).
2019 RECOMMENDATION #3 - UH/HMEC recommends that the 2019 State Department of Human Services and other stakeholders explore the mechanisms to obtain Federal Medicaid GME funding since many of the residency programs provide inpatient and ambulatory care for Medicaid populations.
• To be explored further. Not yet started.
5.       Additional Items·         Next HMEC meeting: Monday, October 28, 2019 at 7:30 am, JABSOM MEB 202.
6.       Adjournment·         Meeting adjourned by Lee Buenconsejo-Lum at 9:00 am.