More clinics across Hawaii are securing an important federal designation that will channel additional funding toward health care services in rural areas.

In just three years, nine more health clinics acquired Rural Health Clinic status from the federal government, taking Hawaii’s total from two to 11 clinics. Gaining that designation means clinics will receive higher reimbursement for treating patients who are insured by Medicaid and Medicare, with the federal funding keeping the facilities financially afloat.

The Big Island clinic Kipuka O Ke Ola got its RHC designation in 2017, but the process took nearly two years, according to Claren Kealoha-Beaudet, the clinic’s executive director and a practicing psychologist.

With a mission to serve Native Hawaiians and other underserved populations, gaining the RHC status has been crucial, she said.

“We would not be able to survive without it, especially as an independent clinic,” Kealoha-Beaudet said. “Because of the reimbursement, we’re able to provide that extra degree of support.”

Colin Edsman

Most of the clinics provide services that would otherwise be difficult to access, especially in more isolated areas. Hawaii is home to approximately 1.43 million people, about a third of whom are considered to live in a rural area and experience more obstacles to accessing medical care.

Rural and medically underserved communities identified by the Health Resources and Services Administration tend to experience disproportionately higher rates of some diseases such as diabetes, hypertension and cardiovascular problems.

The University of Hawaii’s Physician Workforce Assessment for 2018 found that Hawaii has a shortage of about 800 doctors, when compared to average demand for doctors on the mainland. Primary care, mental health, substance abuse and oral health care are areas of significant need, and many neighbor island residents must fly to Oahu for care.

“Due to our island geography and separation by water, access to care in isolated areas is one of the largest issues Hawaii faces and rural health clinics play an important role in meeting that need,” said Allison Mikuni, a program specialist at the Hawaii Department of Health Office of Primary Care & Rural Health.

Kipuka O Ke Ola — formerly Five Mountains Hawaii Inc. — partnered with the Waimea Hawaiian Homesteaders’ Association and Waimea Hawaiian Civic Club to identify particular health needs in the community. Because of money from its RHC status, the clinic is able to offer primary care, psychological, psychiatric services as well as assistance in applying for social assistance.

“What we have found to be our experience is that if you open a practice, that doesn’t necessarily mean that you’re going to be able to capture the population that is most in need of the service,” Kealoha-Beaudet said. “We provide services such as case management, and we follow up with patients if they don’t have health care, if they need food stamps, or need housing — the social disparities.”

“Because we’re willing to address the social disparities, that’s when we end up breaking down those barriers,” she added.

Rural Health Clinics generally focus on outpatient care, emergency care, and basic lab services in places that have been classified as Health Professional Shortage Areas or Medically Underserved Areas. The clinics may be public, nonprofit or for-profit facilities.

Colin Edsman

Three of the clinics that achieved RHC status in October 2017 are owned by Kaiser Permanente and serve only Kaiser members. Those are the Kihei and Lahaina clinics on Maui and the Kahuku Clinic on Oahu.

Sheila Mackertich, the director of Medicaid at Kaiser Permanente, said it took about a year and a half to complete the paperwork and an on-site survey.

“We can use those dollars to reinvest,” she said. “Depending on the score of your underserved designation in the state itself, it allows us ideally to recruit more physicians and nurse practitioners, in areas that are really challenging to recruit them.”

Three more of Kaiser’s Big Island clinics – Kona, Hilo and Waimea — are in line to receive the Rural Health Clinic status.

One of the challenges in getting the special status is proving certain communities are indeed serving a rural or underserved community.

“The state recognizes Maui county as a rural county and most of Maui is rural. However, the federal government actually lists the Maui entire county as metropolitan, not rural,” said Scott Daniels, a DOH Office of Primary Care & Rural Health program specialist based in Hilo. “In the fed’s eyes, Kahoolawe is metropolitan. It’s bizarre.”

Kealoha-Beaudet saw that play out in her North Hawaii community of Waimea, where the average median income was being skewed by higher incomes among some North Hawaii residents, many retired. Doctors who are no longer in practice but are counted by the federal government also muddied the true need, she said.

“There’s a lot of wealth here and a lot of resort areas — people with lots of money, and then you have those who have very little,” Kealoha-Beaudet said. “In order for you to get the designation, you have to demonstrate that there’s a need in your community, so if there’s a lot of wealth and a lot of physicians, you can’t demonstrate need. We had to advocate for the feds to take a deeper look at that and try to take that into consideration.”

The process is well worth it, says Lisa Rantz, who has served as president of the Hawaii State Rural Health Association since January.

“The whole idea of developing a RHC is that it increases patient access to care, because our doctors’ offices are full, or they’re retiring and there’s no one stepping up to take their place,” she said.

Kaiser Permanente

Rantz, who also serves as the executive director of the Hilo Medical Center Foundation, said she worked for months to get all of Hawaii County designated as a Health Professional Shortage Area. Kauai County and Maui County are also expected to get the official geographic “shortage area” designation this September.

Rantz says the status could open the possibility for more clinics to become considered Rural Health Clinics and take advantage of the federal assistance.

“The more you understand, you ask why haven’t we done this before?” she said. “A lot is because of the timing — an increasing population, a decreasing number of primary care providers — it’s kind of the perfect storm.”

Kaiser Permanente, which operates three of the clinics mentioned in the story, is one of several funders of health care reporting at Civil Beat. Read our policy on outside funding.