At 100 days: Hospital transition has some hiccups

Island physicians give mixed reviews for Maui Health System’s first three months

Motorists arrive at the front entrance of Maui Memorial Medical Center in July after Maui Memorial, Kula Hospital and Lanai Community Hospital transferred July 1 from the quasi-public Hawaii Health Systems Corp. to the Kaiser Permanente-affiliated Maui Health System. Island physicians have mixed but hopeful opinions about the changeover’s success so far. The hospital’s electronic patient records system and physician reimbursements are among early problems. -- The Maui News / MATTHEW THAYER photo

When Dr. Samuel Lyons sat on the Maui Regional Board that had to select a private health care provider to operate three Maui County hospitals, he and the other members were all in agreement — Kaiser Permanente was the one for the job. 

Lyons saw the success of Kaiser on the national level, the vast resources that could help improve the hospitals and Kaiser’s longtime ties to the community. Now, however, Lyons wishes he’d voted differently. 

“We understood that Kaiser took on a tremendous challenge,” said Lyons, the owner and managing partner of Lyons Care Associates. “And so I think we were willing to give them some growing time. . . . But I began to be concerned when certain very, very basic things just aren’t addressed.”

As the change in management at Maui Memorial Medical Center, Kula Hospital and Lanai Community Hospital marks its third month, physicians in the community have mixed but hopeful reviews. Some share the experiences of Lyons, who wrote an Oct. 3 Viewpoint in The Maui News explaining his struggles to work with Kaiser. Others have seen signs of progress; they just think the new management needs more time. 

“I think you have to give the folks at Kaiser — and I’m not a Kaiser physician; in fact, they’re our competition — credit for the fact that they had an enormous amount of work to do,” said Dr. William Mitchell, president and chief executive officer of Maui Medical Group. “The Maui community hospital is doing what it needs to do. It’s not perfect, but it’s certainly getting better.”

On July 1, Kaiser affiliate Maui Health System assumed operations at the three hospitals. The Maui Region of the statewide, quasi-public Hawaii Health Systems Corp. had been struggling financially, and hospital officials had tried for nearly a decade to find a private partner. When everything finally fell into place — the law allowing the hospitals to seek a private partner, the unanimous vote for Kaiser, the settled union disputes over state workers going private — just about everyone expressed relief. 

Legislators called it a victory a long time in the making. Hospital officials were hopeful in anticipation of the resources and doctors Kaiser would bring. Kaiser leadership pledged improvements that would allow more patients to stay on Maui and receive better care. 

One of the first changes started with the electronic system.

 ‘Uncharted territory’

For hospitals and physicians, a basic but vital aspect of health care is the records and billing system. Kaiser introduced a new electronic system to the hospitals, and while Lyons said he knew it would take some time to adjust, the lack of synchronization is proving costly.  

Under the old system, the records for patients getting treated at the hospital would automatically be sent to patients’ doctors, Lyons said. However, that’s no longer happening, so Lyons and his staff “have to put together the whole (hospital) encounter from scratch.” That adds time to each patient visit and makes it more difficult to bill patients efficiently. Because it’s such an important function, Lyons said he thinks the issue should’ve been settled by now.

“Not only are we not getting our bills out, but we are having to pay more staff to take longer hours in order to get documents that used to come to us automatically,” Lyons said.

“I don’t want to subsidize their transition by having to work longer or having to use things that I wouldn’t ordinarily use while they kind of figure it out.”

Mitchell said the new electronic system “was a big part of the whole changeover.” He pointed out that Kaiser is having to work with a wide variety of non-Kaiser physicians in the community. And, it’s not only new physicians, but also new insurance companies that have to be incorporated into the billing system.

“Kaiser traditionally did not have to deal with different kinds of insurances, and now they do,” he said. “They had to create the ability to report data to physicians in the community with different types of codes and information that they normally didn’t need to do. This was, I believe, uncharted territory on their side.”

It took Maui Medical Group a few weeks to get in sync with the new system.

“It was inconvenient and frustrating, but not impossible,” Mitchell said. “We’re a big group, so we have a lot of staff here. It may be a bigger problem for a physician in a very small office.”

Dr. Arthur Chasen, a private practice general surgeon and the former trauma director at Maui Memorial, is concerned about those smaller practices. 

“Within a short period of time, there’s a little crisis brewing in the private practice physician world because they can’t bill,” Chasen said. “A private practice surgeon is a small business. He’s got employees he’s got to pay. He’s got rent he’s got to pay. He’s got malpractice insurance he’s got to pay. And all of that is paid for when the dictation gets submitted for a bill. If they (Kaiser) overlook that or don’t do that, all of a sudden the private practice surgeons are being smoked out.”

Maui Health System spokeswoman Chastell Ely said the hospital administration has invested “significant funds and resources” in technology.

“In the past, community doctors have received data by fax, and some would like to continue to do so,” Ely said. “We are working on the integration of systems that would automate that process, and expect to have that capability in the coming month. In the meantime, we have hired staff to manually fax the documents so our community partners can continue to receive data in the way they prefer.”

Wait for reimbursements

Maui Medical Group is a private practice of 55 physicians and 25 “mid-levels” like nurse practitioners and physician’s assistants. The group also has 14 full-time physicians known as “hospitalists” based at Maui Memorial to handle patients who don’t have Kaiser insurance.

“Kaiser had told us they would not be changing any of the contracts and that they would continue to reimburse physicians for their after-hour call coverage,” Mitchell said. “Also, we have that large hospitalist contract. We were told that would be continued.”

As promised, the hospitalists have been paid regularly. However, the hospital “has been slow to pay some of the physicians who do after-hours calls,” Mitchell said. “We are just starting to get payments for that.”

It’s a different story for Lyons, who has yet to see his payments start coming in.

“In the transition from HHSC to Kaiser, my call contract sort of got lost in the scuffle,” Lyons said. “For three months and literally thousands of dollars now, I have been doing uncompensated calls, with no explanation.”

The new system has helped some, like Dr. Elizabeth Mannick, a private practice physician specializing in pediatric and adult gastroenterology. She wasn’t getting reimbursed long before Kaiser took over. Mannick does daily rounds at Maui Memorial and is on call every day of the year. While it took a couple of months to work out a contract, she finally started getting paid last week after nine months.

“It’s been a breath of fresh air because with the new Kaiser administration and the new contracts person, I’m finally getting a new contract and some call compensation,” Mannick said.

Mannick said her understanding was that Kaiser was allowing people to get used to the transition over the first six months before making major changes. That’s why she’s “not surprised or shocked or particularly disappointed that there haven’t been a lot of changes yet.”

“I think once a year has gone by, we’ll really have a very good feeling for what’s working and what’s not working,” Mannick said. “It’s a little early, but I realize that there are frustrations.”

Ely did not specifically address Lyons’ case or why certain reimbursements were delayed, except to encourage physicians to contact the administration to “resolve individual issues.”

‘Test case’ for Kaiser

Because Kaiser oversees three county hospitals, and since Maui Memorial is the only acute-care hospital on the island, some physicians are cautiously watching to see how the health care provider interacts with community doctors.

“In a way, I consider myself and Dr. Lyons as kind of like the test case of Kaiser’s ability to work with the community,” Chasen said. “If the management of the hospital is preventing private practice from surviving, then they’re kind of, in essence, forcing a monopoly on health care. I don’t think they’re doing that. But like I said, we’re like the canary in the coal mine. If we can’t survive, then that means the health system is going down.”

For now, Chasen is “giving them the benefit of the doubt.” And, some say Kaiser is sending positive signals.

Dr. Constantin Novoselsky is the medical director of Maui Medical Group’s hospitalist team. He said Kaiser leadership has been open to suggestions from Maui physicians and has “strongly encouraged” them to get involved in hospital decisions.

“It is difficult for community physicians, and for us as well, to suddenly become more involved in hospital life,” Novoselsky said. “We are used to somebody else making decisions for us and then us complaining about these decisions. Kaiser gives physicians this ability to be in charge of the hospital, and I think it is important for the community physicians to step up to the plate and to fill those leadership roles.”

For example, physicians can join committees, such as the Pharmacy and Therapeutics Committee that advocated for Kaiser to allow medications that doctors in the community already use but that Kaiser hasn’t adopted yet, Novoselsky said. 

“Of all the promises, the most encouraging change so far is the fact that they’ve hired a lot of nurses from UH Maui,” Novoselsky said. “This is something they’ve promised — not to rely a lot on the traveling nurses and support local grads.”

In response to Chasen, Ely said that new Chief Executive Officer Michael Rembis “has a strong background in community hospital leadership” and is willing to work with community physicians to create a successful hospital system.

“Maui Health System can only be successful if our community partners are successful, so we welcome all constructive input and suggestions,” Ely said.

‘Still a big job’

Regardless of his frustrations, Lyons still believes Kaiser is capable of bringing about change. He just thinks officials need to provide more timely responses to important issues.

“They’re not having to recreate the wheel here. They’re just having to duplicate stuff that’s already being done,” Lyons said. “They suffer from not having any competition. I can tell you that if there were another hospital on this island, and there was competition, this would’ve been solved just like that, because if it weren’t solved, doctors would be walking down the way, patients would be going down the way.”

West and South Maui Sen. Roz Baker, who along with other Maui lawmakers advocated heavily for the transition, said she met with Rembis and didn’t see reason for concern just yet.

“I haven’t heard any complaints from individual doctors nor complaints about patient care — quite the opposite,” Baker said via email. “First, the transition is not even six months old. I certainly didn’t expect everything that needed to be done for MMMC would be accomplished immediately, certainly not the IT system. I do know that it is a priority and work is being done.”

Ely pointed to the growing changes.

“We’ve increased full-time employees and reduced temporary traveler staff by half, which stabilizes the workforce, hired close to 50 local graduates and invested significantly in new technology to support employees and physicians in delivering safe, high-quality care,” Ely said. “We have experienced some challenges, and MHS is addressing them as quickly, efficiently and thoughtfully as possible.”

In Mitchell’s eyes, the issues so far have been temporary inconveniences that can be overcome.

“Kaiser has a lot of things they’ve got to balance here, not only physicians’ needs but most importantly the patients’ needs,” he said. “It was a big job. It still is a big job.”

• Colleen Uechi can be reached atcuechi@mauinews.com.


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