July 26, 2021

MEETING  ANNOUNCEMENT

Hawaii Medical Education Council
Monday, July 26, 2021
7:30-8:30 am

This meeting will be held in-person, with
physical distancing enforced, and also
available via video conferencing using Zoom.

The physical in-person location will be held at
the John A. Burns, School of Medicine,
651 Ilalo Street, Room #MEB 202
Honolulu, Hawaii 96813

Please contact Crystal Costa via costaca@hawaii.edu
for Zoom meeting access at least 3 business
days before the meeting date above.

Requests for auxiliary aid/service or other accommodation due to a disability, please contact
Crystal Costa via email at costaca@hawaii.edu by July 19, 2021, 4:00 PM. Accessibility
access is not guaranteed for requests received after this date. Upon request, this notice is
available in alternate formats such as large print, Braille, or electronic copy.

AGENDA

1. Review & Approval of April 26, 2021 Minutes – Dr. Hedges (to be distributed via email to members on 07/19/21)

2. Report from HMEC Chair – Dr. Hedges
a. Announcements/Discussion (5 minutes)
b. Graduate Medical Education updates – Lee Buenconsejo-  Lum (10 minutes)
i. GME Program Prioritization Process/Potential      Expansions
c. Update on Legislative Strategies – Jerris Hedges and Cynthia Nakamura (10 minutes)

3. Physician Workforce Data Updates & Synergies – Aimee Grace & Kelley Withy (30 minutes)
a. Preceptor Tax Credit Update
b. Physician Workforce Update
c. Federal Appropriations Update

4.  New Business – Dr. Hedges (5 minutes)

5.  HMEC Recommendations confirmed to the 2021 Legislature – Lee Buenconsejo-Lum

RECOMMENDATION #1
UH/HMEC recommends that the 2021 State Legislature and State Executive Branch continue to support and provide a
State financial match to the Hawaii State Loan Repayment Program. Ideally, this match would 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 repayment program for
Hawai‘i – including coordination of the National Loan Repayment Program Federal match for Hawai‘i.

RECOMMENDATION #2
UH/HMEC recommends that the 2021 State Legislature and State Executive Branch provide funding to support the
JABSOM faculty and staff, as well as both the medical student and residency curricula. The curricula needs support in
order to maintain existing medical student and resident rotations on the neighbor islands, and to maintain currently
existing innovative programs which serve to meet the needs of underserved communities.

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

6.  Additional Items – Next HMEC Meeting – Monday, October 25, 2021 @ 7:30am in-person and via Zoom

7.  Adjournment

Minutes

Members Present:  Mary Ann Antonelli (representing the federal healthcare sector), Nicole Apoliona (representing the health professions community), Lee Buenconsejo-Lum (Associate Dean for Academic Affairs, Designated Institutional Official (DIO) for Graduate Medical Education, JABSOM), Leslie Chun (representing a hospital conducting ACGME programs), Katherine Finn Davis (for Dean of Nursing, representing the Nancy Atmospera-Walch School of Nursing), Jerris Hedges (Chair, JABSOM Dean), Robert Hong (representing the health professions community), Lorrin Kim (for Elizabeth Char, representing the Department of Health), Judy Kovell (representing a hospital conducting ACGME programs), Lisa Rantz (representing a person of the general public), Joe Ramos (for Randall Holcombe, representing the UH Cancer Center), Linda Rosen (representing the health professions community), and Todd Seto (representing a hospital conducting ACGME programs).

Members Absent:  N/A

Others in Attendance: Chip Ellis (CFO, University Health Partners of Hawai‘i), Jami Fukui (UH Cancer Center representative), Aimee Grace (Director of UH System Office of Strategic Health Initiatives), Marlene Keawe (COO, Hawai‘i Residency Programs, Inc.), Holly Olson (Deputy DIO, JABSOM), Hilton Raethel (President & CEO, HealthCare Association of Hawai‘i), Larry Shapiro (CEO, University Health Partners), Susan Steinemann (Assistant DIO, JABSOM) and Kelley Withy (Director, AHEC).  

Minutes Approved:  CC 10/XX/21 (Recorders Initials & Date)

Acronyms: ACGME = Accreditation Council for Graduate Medical Education; AHEC = Area Health Education Center; AAMC = Association of American Medical Colleges; CEO = Chief Executive Officer; CFO = Chief Financial Officer; CMS = Centers of Medicare & Medicaid Services; COO = Chief Operating Officer; DCCA = Department of Commerce and Consumer Affairs; DIO = Designated Institutional Official; DOH                                                                                             

HMEC Administrator:  Lee Buenconsejo-Lum Recorder: Crystal Costa

 

TOPICDISCUSSION/CONCLUSIONS/ACTIONS/DECISIONSACTIONS
1.Review of MinutesMinutes from our last meeting, held on 7/26/21, were reviewed and approved without any changes.  The motion for approval came from Dr. L. Chun and were seconded by L. Rantz. Approval was unanimous. No members abstained. Voting was conducted by raising hands for those in person and attending via Zoom. Links to websites and resources will be embedded into the meeting minutes for convenience.   NA.
Chair Report - Dean J. Hedges Announcements (Jerris Hedges) Dean Hedges introduced our newly nominated council member, Dr. Colleen Inouye. Dr. Inouye is a strong advocate for medical education and will contribute a neighbor island perspective as she currently resides on the island of Maui.

GME Institutional Self-Study (Dr. Lee Buenconsejo-Lum) The Accreditation Council for Graduate Medical Education (ACGME) requires JABSOM, as the Sponsoring Institution (SI) for 19 GME programs, to draft an Institutional Self-Study document that will be due in April 2022. The purpose of the Institutional Self-Study is to provide a framework to improve graduate medical education (GME) by developing and implementing a strategic plan aligned with an institutional GME mission. A writing group task force has been meeting to work on developing the document, outlining aims and action plans by reviewing data from the last five years. This document is meant to be brief with each section assigned a word limit. Sections include addressing the mission, opportunities, threats, aims (SI, linking the JABSOM GME programs to the National Learning Community) and action items for the SI. The Council reviewed the current Self-Study draft and discussion followed. Three aims for the SI include integration of quality and patient safety, expansion of rural training experiences and best practices for geriatric care through integrated regional care networks. Aim one aligns with our current initiatives while aim two and three align with national efforts. Population health, rural expansions and integration will need to be strengthened and prioritized to develop greater faculty support. Changes in healthcare delivery and payment transformation may need to be further addressed, i.e., provide focus on training and building team-based care and interprofessional teams with careful consideration toward rural settings. The Council recommended being more explicit with team-based care as it serves as the foundation for alignment with the health systems. GME Program Prioritization Process/Potential Expansions (Dr. Lee Buenconsejo-Lum) Two programs will be aiming to expand in the upcoming academic year as follows:
- Cardiovascular Disease Fellowship Program – increasing from 9 to 12 fellows with a budget currently under review.
- Surgery Residency Program – will be submitting proposals to convert 2 preliminary positions to categorical positions which would create 5 residents per year with the intent that the program will be able to increase surgeries and rotational experience in rural areas such as North Hawaii and other areas. Funding to qualify with HRSA and other grants remain challenging as the criteria to meet requires “rural” designations for the hospitals but all of Oahu is considered urban except for Kahuku, which would allow this area to be eligible for certain grants. Next steps include having additional conversations with the hospitals systems to gauge interest in possible grant applications. Timelines are tight and budget adjustments would impact 2024. CMS has not yet released their “final rule” which would directly impact provisions and provide criteria for the additional 1000 GME positions that are slated for distribution over the next few years, based on institutional qualifications. Interested parties may contact Dr. Aimee Grace to partner on these federal priorities via email at amgrace@hawaii.edu.		NA. Informational only. Ongoing updates.



The Council will be asked to continue reviewing and providing feedback on the Self-Study document.
1. Physician Workforce Data Updates & Synergies Dr. Kelley Withy + Dr.Aimee GracePreceptor Tax Credit (Dr. Kelley Withy)
The tax credit is on track to beat the record from the last two years and has issued $370K of relief to preceptors. There are 773 preceptors registered with 73 new preceptors. There have been some complaints from preceptors who have not been able to qualify as the criteria require preceptors to be primary care or in a closely related field. A request to amend the definition has been submitted to broaden the categories for preceptor qualification and type of employment. The committee is looking into how to expand eligibility in the upcoming legislative season.
Physician Workforce (Dr. Kelley Withy)
There are currently 10,592 licensed physicians in Hawaii, with a current supply of 2,857 Full Time Equivalent (FTE) practicing physicians (3,293 available but not full time) which shows an increase of 45 FTEs from 2021. At least 71 retired, 9 passed away, 154 moved away, and 46 decreased work time. There were 150 physicians new to Hawaii, and 28 returned to Hawaii. These numbers also include 10 physicians from the Veteran’s Affairs who have an out of state license but are working in Hawaii. The physician shortage is around 700 when you examine island and specialty specific needs. The average physician age in Hawaii is 54.6 years, which is 3% higher than the national average (51 years). Concerns remain regarding our aging physician workforce with 48% already over 55 years and 22% over 65 years and five practicing physicians over 90 years. Women in the workforce have increased by 1% from last year at 38%. A new demand model is impacted by a slower increase in the population (rising 4% lower), less national service use, and the specialties category has been re-defined to include more subspecialties and pediatrics.
Help is needed and underway to identify needed specialties and the appropriate numbers of physicians that are needed to provide services throughout the state. The Council discussed challenges in maintaining a skillset if the volumes are not high enough for some specialties. The Council recommended and considered essential specialties which included the ICU and those that require hands-on intervention to preserve life and function. A critical mass is needed for general surgery, orthopedic surgery, neurosurgery, possibly urology, and cardiology. Additional recommendations are to focus on local needs as opposed to national means to get a more accurate picture of usage with a potential to share partial FTEs between counties. Questions that arose during the discussion revolved around accounting for changing expectations in payment transformations, why Americans are using fewer services, how do Urgent Care clinics impact services, and considerations for other models that could be helpful in identifying visit volume in the state which may not be what the state actually needs.

Federal Physician Workforce/GME & Updates from the Consolidated Federal Appropriations Act of 2021 (Dr. Aimee Grace)
As a recap, the Resident Physician Reduction Act of 2021 had proposed the addition of 14,000 new Medicare-supported GME positions. The Consolidated Appropriations Act of 2021 included 1,000 new Medicare-supported GME slots, with priority criteria for qualification including hospitals that are in a rural area, over the CMS resident cap, in a state with a new medical school or branch campus, and serving Health Professional Shortage Areas (HPSAs). This was the first increase in Medicare GME positions in approximately 25 years.

As mentioned during the last HMEC meeting, Hawaii is not well prioritized with these existing criteria, and efforts have been ongoing with AAMC and congressional staff to expand or add certain criteria to better prioritize hospitals in Hawaii. Initially, with regard to CMS’ implementation of the initial 1,000 slots, CMS has proposed alternatives to the interpretation of the law, such as ranking hospitals based on HPSA score (the highest HPSA score will be given a slot) or giving priority to hospitals that meet all four criteria for a qualifying hospital” under the law. CMS proposes to distribute 200 slots per year over the next five years, limiting 1 FTE per qualified hospital per year and noting that those in mental health HPSAs would only be prioritized for psychiatry residencies. JABSOM is supporting the AAMC’s recommendations to CMS to not limit to 1 FTE or give less than 1 FTE and to expand the HPSA definition such that hospitals within 25 miles of a HPSA would be included. We have to wait for CMS’ final decision on these recommended changes.
We have recognized that the best path forward to prioritize Hawaii hospitals would be to advocate to amend any forthcoming bill to establish more GME spots with language to expand the rural criterion to include non-contiguous areas, and also adding a new criterion for hospitals whose sponsoring institution for their GME program or programs is a Minority-Serving Institution (like UH). As these Minority-Serving Institutions address specific populations, proposed new legislation is being considered for a Minority Physician Workforce Act.

UH President David Lassner has sent recommendations with these priorities to national leaders in the Senate, House and committees of jurisdiction, and also included a request to increase Hawaii’s Medicare work Geographic Practice Cost Index (GCPI) to be on par with Alaska (1.5 as compared to Hawaii at 1.010). Ongoing work continues to develop a Federal Health Workforce Strategies white paper with multiple stakeholders and build partnerships with key University of Alaska and other partner to advocate for the non-contiguous areas. Strategies will focus on getting the GCPI on par with Alaska, ensure non-contiguous areas are eligible for and prioritized in the VA residency programs, potentially amending the definition of “rural” to include the entire states of Hawaii and Alaska, and doubling the appropriations for workforce diversity pipeline programs in the Health Resources and Services Administration (HRSA) through Titles VII and VIII.

UH’s Office of Strategic Health Initiatives proposed a UH Rural Health Research Center for FY2022 ($991,605) under the Labor, Health and Human Services, Education subcommittee under HRSA. This project would be to establish a center that focuses on rural health workforce policy and health equity to conduct high-quality and policy-relevant research and develop policy recommendations to improve rural health care in Hawaii. Updates and monitoring of federal negotiations and appropriations will be followed closely with hopes that bills will be passed for FY2022.
Ongoing updates to be provided by Dr. Withy and Dr. Grace. Drs. Withy and Rosen to connect offline to further discuss alternative models to review.
1. HMEC Recommendations to 2021 Legislature
L. Buenconsejo-Lum
RECOMMENDATION #1
UH/HMEC recommends that the 2021 State Legislature and State Executive Branch continue to support and provide a State financial match to the Hawai‘i State Loan Repayment Program (SLRP). Ideally, this match would 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 repayment program for Hawai‘i - including coordination of the National Loan Repayment Program Federal match for Hawai‘i.
Discussion: Lorrin Kim (DOH) submitted a request to include SLRP into the DOH budget and unfortunately may not be able to make up the resources this year. The request to the legislature will be submitted to make the program whole. The DOH will support a standalone bill but it was not submitted as part of their overall budget as they will be focusing on saving current programs after recent losses from the past year. DOH remains committed to support initiatives however they can. There is a new grant out that may not require the match which might be helpful with obtaining more funds which Dr. Withy will be investigating further. Maui and Hawaii county provided the matches for the neighbor island candidates.

RECOMMENDATION #2
UH/HMEC recommends that the 2021 State Legislature and State Executive Branch provide funding to support the JABSOM faculty and staff, as well as both the medical student and residency curricula. The curricula need support in order to maintain existing medical student and resident rotations on the neighbor islands, and to maintain currently existing innovative programs which serve to meet the needs of underserved communities.

Discussion: Considerations were discussed about continuing to include a JABSOM training site expansion on the neighbor islands. While the Council is unsure about the budget support for a satellite campus, some sort of expansion to provide flexibility was recommended.
RECOMMENDATION #3
UH/HMEC recommends that the State Department of Human Services and other stakeholders develop a working group to explore the mechanisms and to develop a plan to obtain future Federal Medicaid GME funding since many of the residency programs provide inpatient and ambulatory care for Medicaid populations.

Discussion: Dean Hedges and Dr. Buenconsejo-Lum met with Judy Mohr Peterson and she agreed to keep this recommendation under consideration.
Informational only.
Additional ItemsAll participants present for the duration of the meeting. Next HMEC meeting: Monday, January 24, 2022, at 7:30 am, location via Zoom.
AdjournmentMeeting adjourned by Dean Hedges at 8:25 am.