Kanani: How are the state budget cuts affecting health care so far? What would be your top concern going forward about the health care system as a whole?

Art Ushijima: The cuts are beginning to have an impact on uncompensated care at Queen's and at other Hawai'i hospitals. In (fiscal year) 2009, which ended in June, Queen's incurred $33 million in uncompensated care against a budget of $27 million. Other impacts of the economy include the withholding of disproportionate share payments to Hawai'i's hospitals, which amount to nearly $20 million which would be used to support those unable to pay for their care.

K. Carter: As baby boomers (like myself) begin to age, do you think our country's health care system is moving toward a crisis?

Art Ushijima: Like you, I'm in the large pool of 77 million aging baby boomers in the nation. The rising costs of Medicare — currently over $600 billion annually — are a major issue facing the health care industry and the nation. Currently, Medicare enrollment is increasing by about 500,000 enrollees annually. When the front end of the baby boomers reaches 65, that annual increase could be as high as 3 million annually. So there is an impending Medicare challenge to meet the increased demand for care along with the cost of providing this.

Lisa: Do you think if we implemented tort reform here, we would be able to recruit and retain doctors?

Ushijima: Dealing with tort reform is only one of the issues around physician recruitment and retention. The whole legal and regulatory and compliance requirements require review, as they add significant costs to our operations. When I joined Queen's 20 years ago, we had one lawyer on staff. Today, we have six. This reflects the complexity of the legal environment we operate within.

Puulani: Why is the swine flu so severe, and with forecast of half the population getting it this fall, are we ready? Is Queen's Medical Center ready?

Art Ushijima: I believe, because mortality to date has been rather low, people have not taken adequate precautions, e.g., staying home when ill; not washing hands. So, the spread of H1N1 has occurred at higher rates and may increase further unless people observe reasonable preventive measures. Queen's will continue to work with federal, state and city agencies to be well informed and prepared on this issue. We have prepared our workers with surgical masks, hand sanitizers and other precautionary measures to mitigate the spread of H1N1.

Marie Barnes: Is the Queen's Health Systems still committed to providing quality care to Native Hawaiians?

Ushijima: Yes. We recently celebrated the completion of the redevelopment of our Moloka'i General Hospital, which involved seven years of fundraising efforts and 29 months of construction over a four-year period. More than 60 percent of Moloka'i's population is Native Hawaiian, and Queen's provides more than $2 million annually to subsidize care at Moloka'i General. Additionally, we have implemented a Native Hawaiian Health Program at Queen's with a vision to enhance the well-being of Native Hawaiians. We have developed programs in a number of clinical areas such as heart care, diabetes, and comprehensive weight management and cancer.

In cardiac care at Queen's, mortality rate for Native Hawaiians undergoing open-heart surgery decreased to 0 percent from fiscal year 2006 to fiscal year 2008. Queen's also supported the establishment of the John A. Burns School of Medicine Department of Native Hawaiian Health, providing $5 million.

KaneoheGirl: I believe the public option — government-sponsored health insurance — is necessary to keep the expansion of coverage from becoming a windfall for private companies. What do you think? Will expanding public insurance really mean death for private insurance, as some companies say?

Ushijima: Hawai'i already has a reasonably successful program under the Prepaid Healthcare Act, which has resulted in one of the lowest uninsured rates in the country for health care. Before a public option is decided, we must define it. If the public option is similar to Hawai'i's employer mandate, it could be beneficial for the nation. If the public option is an expansion of Medicare or Medicaid, there could be unintended consequences.

What is important today is to clearly define the parameters of any financing system — governmental taxation, employer mandate, or other means — along with coverage needs that are currently unmet by the present system.

Carl: I heard on NPR that there is a new program where there is a pay incentive to doctors if they keep their patients healthier. Also, the program encourages the doctors to spend more time with the patient and not rushing them off so they can get more billings from the insurance companies. Have you heard of this and if so, is Queen's Medical Center going in this direction?

Ushijima: The care delivery model you're probably referencing is called "medical home" where a primary care physician, e.g., internist; family practitioner; is provided a "pool" of funds to care for a defined group of patients in his/her practice. The incentive for the physician is to minimize the potential of increasing office visit fees and to devote as much time and energy for prevention and wellness. The notion is to keep patients well through programs such as diabetes prevention; weight management; etc. We are working with HMSA and several other organizations to develop a pilot program for a medical home model. We are at a very early stage of this, but we feel this has significant potential benefits.

Carol: How does Queen's Medical Center handle homeless and uninsured people who show up at the emergency room? Do you get reimbursed for this or do you take the loss?

Ushijima: Any patient who presents himself to the ER will receive care regardless of ability to pay. This is part of our mission, as well as our moral and legal obligation to any patient. This cost is borne by the hospital and we rely on other services where we make a margin to cover the cost of uncompensated care. In fiscal year 2009, which ended in June, we incurred $33 million in uncompensated and charity care against a budget of $27 million.