Hawaii boasts a strong commitment to Public Health and Injury Prevention, for which it ranks second in the nation, as well as a top-notch emergency medical services (EMS) system focused on patient safety and quality of care. However, a severe gap in hospital capacity impedes the state's ability to respond to both everyday emergency care needs and potential disasters or mass casualty events.
Hawaii continues to stand out in Public Health and Injury Prevention. The state has both low rates of chronic disease and low rates of fatal injuries in almost all measured categories. These stellar numbers are supported by the state's fiscal commitment to injury prevention, with high per capita injury prevention funding ($961.64 for every 1,000 people) and funding sources specifically set aside for prevention of occupational injuries, childhood injuries, and injuries among older adults. Hawaii also has some of the lowest rates of adult and child obesity in the nation.
Hawaii has greatly improved its Quality and Patient Safety Environment since the last Report Card. The state has adopted a uniform system for providing pre-arrival instructions and has implemented a statewide trauma registry. Hawaii is ninth in the nation in terms of hospitals with computerized practitioner order entry (87.0%). It provides funding for quality improvement within the EMS system and has a funded state EMS medical director, demonstrating a strong commitment to quality improvement and system oversight.
Although Hawaii has numerous challenges related to Access to Emergency Care, the state ranks among the five best states for the proportion of adults (91.0%) and children (95.9%) with health insurance. Rates of underinsurance for both adults and children are also well below the national average.
Challenges.Hawaii's poor grade in Access to Emergency Care is primarily due to a lack of adequate hospital capacity, which can lead to dire outcomes. The closure of two hospitals in 2011 could be a contributing factor to a sharp need for beds and treatment centers, and Hawaii's isolated geography keeps its people from taking advantage of facilities in other states. Hawaii has one of the highest per capita rates of emergency physicians but few emergency departments (ED; 9.3 per 1 million people). Its hospitals are nearly at capacity, with the second highest hospital occupancy rate in the nation (77.1 per 100 staffed beds) and low numbers of staffed inpatient beds overall (231.9 per 1 million people), which contributes to long waits in the ED (330 minutes from ED arrival to departure). Other contributing factors to Hawaii's poor grade include low Medicaid reimbursement rates and shortages in some specialties, such as neurosurgeons and ear, nose, and throat specialists.
Hawaii's infrastructure problem is echoed by challenges in Disaster Preparedness. The state has no verified burn centers and low numbers of burn unit beds (2.2 per 1 million people), the lowest per capita rate of intensive care unit (ICU) beds in the nation (117.8 per 1 million), and the second lowest bed surge capacity (229.8 beds per 1 million). These infrastructure issues will greatly hamper Hawaii's ability to respond to a large-scale disaster or mass casualty event.
Hawaii's subpar grade for its Medical Liability Environment is aided by relatively low numbers of malpractice award payments (1.5 per 100,000 people) and average medical liability insurance premiums for primary care physicians ($10,432) and specialists ($44,860). Offsetting these relative advantages are few protections for the state's health care workforce and the highest average malpractice award payments in the nation ($681,839).
Hawaii has high rates of insurance and plenty of doctors overall, but gaps in hospital and treatment facility capacity are highly problematic and lead to overcrowding, long waits in the ED, and poor overall Access to Emergency Care. Increasing the availability of medical facilities, ICU beds, burn beds, EDs, and inpatient beds would go a long way toward improving the state's access to emergency medical care and increase its ability to respond to large-scale disasters.
Hawaii should consider adopting medical liability reforms such as reducing the medical liability cap on non-economic damages to $250,000, requiring awards to be offset by collateral sources, and requiring periodic payments of malpractice awards. These reforms can reduce the incidence of defensive medicine and encourage more specialists to provide on-call services to emergency patients. Additionally, Hawaii should implement expert witness rules requiring case certification; ensure that expert witnesses are of the same specialty as the defendant; and institute liability protections for care mandated by the Emergency Medical Treatment and Labor Act, which requires emergency care providers to perform life-saving procedures without a pre-existing patient relationship and little to no knowledge of a patient's medical history.