By Rod Thompson, Star-Bulletin
Kau Hospital kept him alive last year. Now Israel
Gorali is trying to keep it alive.
Rural areas
fret over
medical care
Some residents fear that cuts
By Rod Thompson and Gary T. Kubota
in funding and jobs could shut
the isles' community hospitals
Star-BulletinPAHALA, Hawaii -- Israel Gorali lay in a diabetic coma for six hours last year at Kau Hospital in south Hawaii, his body temperature falling to 90 degrees.
"When you're dead your body loses its heat," he says.
Gorali credits the rural Kau Hospital in helping to save his life.
Now, he is working with residents to keep the hospital and others like it alive.
From Kau to west Kauai, many people in rural areas statewide are worried they may lose their lifeline to medical care, as the state looks for ways to reduce expenses at community hospitals.
Two years ago, in the face of the need for increasing subsidies for state hospitals, state lawmakers established the Hawaii Health Systems Corp. to operate the 12 hospitals with the expectation that it would reduce costs.
While the law calls for maintaining quality care while operating efficiently, the state has since reduced subsidies to the semiautonomous state agency. Funding has decreased from $24 million in fiscal 1994 to $13 million in 1998.
Lawmakers also decided this year to eliminate 136 vacant positions at the agency, including seven nursing positions at Hilo Medical Center and 11 at Maui Memorial Hospital.
Barbara "Susie" Uwekoolani, a registered nurse at Maui Memorial Hospital, said there is a shortage of nurses, especially those with critical-care skills.
She said trying to rely upon temporary help through nursing agencies is a mistake.
"I think they're foolish in a way," said Uwekoolani, who represents some professional nurses with the Hawaii Government Employees Association.
"They are going to find out they're not able to staff properly. We don't have the number of residents like a big city."
Tom Driskill, the corporation's president, said his group has no plans to close any of the 12 hospitals, nor is it considering that as an option.
"Our corporation is committed to preserving and enhancing both the quality and the level of service in the communities we serve," Driskill said.
Driskill conceded there are a couple of areas where there are nursing shortages. But he said the corporation won't sacrifice quality for cost and is of conducting a review of medical care and staffing.
Driskill said under a new law, the corporation has the authority to create staff positions and has formed a committee with government unions to review personnel changes.
The agency says it has reduced losses by about 50 percent compared with 1997 but still needs to ask the state Legislature to subsidize its operations next year.
Diane Plotts, the corporation's board chairman, said she expects the state will have to continue to subsidize the operation because the hospitals provide medical services for those who cannot afford care elsewhere.
"I look at it as the state purchasing services from the standpoint that we are the safety net," she said.
Plotts said the cost of the state subsidy now totals $13 million, or about 5 percent of the operating expenses -- significantly less than similar hospitals nationwide which require 15 percent.
"To me, if we can hold that level of care under 10 percent, the state is getting a bargain," she said.
Plotts said the financial results have confirmed her feeling that switching from a state-run to a nonprofit operation two years ago was the right move.
"I'm more enthusiastic than ever that it was the right direction," Plotts said.
Plotts said in many Hawaii rural areas, the population does not financially justify a hospital. But she said the facilities are needed, especially for emergency care.
Some residents remain wary of the corporation. They say its report to the Legislature in January is a good example of looking at the bottom line without understanding the community.
The report said emergency rooms at Kau and North Kohala serve an average of three people per day yet cost $600,000 per year to operate.
"In nearly every case, these patients could have been cared for in a regular doctor's office, rather than an emergency room," the report said.
"Additionally, true emergencies are cared for in both communities by the county fire department advance life support rescue units."
Nineteen of Kau Hospital's 21 beds are for long-term elderly care. But most Kau residents think about immediate care when they think of the hospital, said Charlene Hart, who writes a community newsletter.
"They care about the emergency room. They care about the pharmacy," she said.
The possibility of reduced emergency room hours was a red flag for community figure and regional Medical Advisory Committee member Jessie Marques, who called the report to the Legislature "biased and inaccurate."
Marques said the report didn't note the difficulties of providing medical services in a district more than 1-1/2 times the size of Oahu with, until recently, only one doctor.
Marques is eager to see that a "rural health plan for the island of Hawaii" focusing on Kau and Puna, recently mandated by the Legislature, doesn't result in cutting emergency room care.
Marques organized meetings, gathered signatures on a petition and lobbied at the Legislature.
Senate Health Committee co-chairman Andy Levin, who represents Kau, thinks Marques has overstated the threat to the hospital.
"She definitely stirs things up that maybe don't need to be stirred up," he said.
Levin points out that the law prohibits closing any hospital, or reducing its services, without legislative approval.
That's not going to happen, he predicts.
"The governor is supportive. The Department of Health is supportive. The Legislature is supportive," he said.
He noted that the Legislature appropriated $8 million in system subsidies in 1998-99 -- about half of what they corporation wanted.
The Legislature expects the corporation to ask for more in January, he said. "I fully expect we will give them more money."
Gorali, whose life was saved by Kau Hospital and now sits on the Medical Advisory Committee for the region, isn't completely reassured.
"They're going to want to cut out their losses and run," he said. "Anything could happen, and anything could cause the Legislature to change its mind."
West Kauai clings
By Trish Moore
to hope and its
money-losing hospital
Star-BulletinWAIMEA, Kauai -- Mary Costales' four sons, seven of her grandchildren and three great-grandchildren were born at the state hospital in Waimea.
She and her husband, Jose, moved to Kauai's west side when they were first married nearly 60 years ago.
Mary worries about the hospital's future because Jose, 83, has been hospitalized three times in the last year, and the muscular dystrophy crippling her legs means she can't drive.
"I feel more secure with the hospital close by," Costales says. "It's too far for us to go to Lihue."
Costales and other West Kauai residents had a scare late last year when a study jointly funded by the Hawaii Health Systems Corp. and Wilcox Hospital recommended converting Kauai Veterans Memorial Hospital into a long-term care facility and centralizing acute care at Wilcox in Lihue.
The report concluded that the two hospitals together lose $5.7 million a year and that health care for the island would be more efficient if the hospitals consolidated their resources into a centralized system with clinic outposts in the various communities.
But westside residents feel different. More than 300 turned up at a meeting last year to support the hospital.
"The community has stated in no uncertain terms that they don't want their hospitals messed with," says Bob Valencia, a Kekaha resident who has joined supporters of other rural hospitals to lobby the Legislature on behalf of the statewide system.
Linda Faye Collins, land manager for Kikiaola Development Corp., has also fought to keep the hospital afloat, arguing that it is a cornerstone of the westside economy.
"So the hospital goes, so goes the west side," Collins says.
Although the hospital -- as well as the statewide system -- has been scrambling to find ways to reduce costs and beef up services that generate revenue, "we're looking at the fact that a rural hospital is not going to bring in megabucks," says Orianna Skomoroch, administrator at Kauai Veterans.
Operating somewhat autonomously from other state agencies, the system has been able to streamline its purchases and automate patient billing.
The hospital has also launched an aggressive marketing campaign with radio and newspaper advertisements -- something the hospitals couldn't do as part of the Department of Health.
"But we have a lot of straight overhead we can't touch," Skomoroch says.
"HHSC is sort of between a rock and a hard place," says Bill Peay, a member of the Hawaii Health Systems Corp. management advisory committee on Kauai.
"They have to catch patients that would otherwise fall through the system," Peay said. "When that happens somebody has to pay for it. There's just not enough revenue potential yet through paying customers to offset safety net fee structure."
The statewide system is mandated to provide free tuberculosis testing and operate unprofitable psychiatric wards on the neighbor islands.
Although still in an experimental stage, telemedicine is a potential moneymaker for the West Kauai hospital, Peay believes.
"The concept is to use technology to reach outside the walls of the hospital to bring revenues in," he said.
The hospital got a $250,000 federal grant to purchase sophisticated cameras and a teleconferencing system that would enable doctors on Kauai to remotely diagnose and treat a patient in a South Pacific hospital.
Change, struggle
By Gary T. Kubota
mark Hana
health center
Star-BulletinHANA, Maui -- Cecilia Kalalau of Hana is happy that the medical clinic in rural Hana now has two permanent physicians, rather than the previous setup of rotating doctors from a hospital chain.
"I didn't like that -- one doctor says this, one doctor says that," said Kalalau, 73, secretary of the Hana Lani Senior Citizens Club.
"So far, the doctors are working real well. We love them both."
More than a year after switching from a state-run to a nonprofit facility, the Hana Community Health Center appears to have made some significant changes.
The center, no longer under the state, is operated by an independent board made up mainly of Hana residents.
Residents have to look no further than Harry Hasegawa of Hasegawa General Store to complain.
Hasegawa, the center's board chairman, says the change has led to accountability and a quicker means to solve some problems, including raising money for renovations.
It has drawn both praise and criticism from residents.
Some have complained about the lack of an X-ray machine for several months and criticized the state for laying off 12 government employees when it relinquished control of the clinic.
The center decided to reduce staff from six part-time registered nurses to two full-time nurses -- an action that stirred ill feelings among some residents.
The clinic has also changed its handling of emergency calls. The calls are now fielded by ambulance paramedics based in the back of the hospital, instead of an on-call nurse on clinic grounds.
Cheryl Vasconcellos, the center's executive director, said the clinic was overstaffed. "It was difficult to justify a staff of this size when you have 2,000 to 3,000 people in the community," she said.
Just 1-1/2 months ago, the clinic installed an X-ray machine after operating for several months without one -- a piece of equipment needed to help physicians make full diagnoses, clinic supporters say. Officials are leasing the machine, with hopes of getting money from the state Legislature to buy it.
Vasconcellos said a previous X-ray machine turned over by the state was ready to collapse.
She said the change to an independent clinic has not been easy because the state turned over the facility in a dilapidated condition and has not maintained its previous level of funding.
State lawmakers once contributed about $1.3 million to $1.9 million annually. This year, legislators authorized $800,000 of the $995,000 requested by the clinic.
Kalalau said she's worried that the state won't give the clinic enough money and will force the facility to close, eliminating critical health care to residents.
