Hawai‘i Doctor Shortage Has Patients Paying Fees For Fast Care

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Last month, Kiah Bland of Waikiki set out to find a primary care physician. What she assumed would be a painless chore swiftly became a desperate search.

Most doctors in her area weren’t accepting new patients. Those still building their patient base had lengthy waits for an office visit.

Eventually, the 36-year-old found a Honolulu physician who could see her immediately — for a price. The doctor, who does not accept health insurance, explained that it would cost her $200 a month to become a patient.

After a free consultation, during which Bland said the doctor addressed her health concerns in depth and without haste, she decided to buy a monthly membership, sidestepping her health insurance.

“I almost couldn’t find a doctor at all so it was a sigh of relief and totally worth paying for it,” Bland said.

Bland is part of a small but growing number of Hawai‘i residents opting to join direct primary care practices, which do not participate with insurance companies and rely instead on flat monthly membership fees charged directly to patients.

It’s different from concierge medicine, which caters to high-income earners and may charge patients up to $50,000 a year for a membership contract.

Doctors who’ve embraced the model say the dependable income they earn from membership fees, coupled with the savings from no longer having to deal with insurance billing and costly overhead, allows them to deliver more comprehensive care to their patients. Some health concerns can be handled by phone or text message, allowing them to spend more time with complicated patients.

This translates to faster care for patients. A 2024 study by the American Academy of Family Physicians found that 99% of direct primary care practices provide same-day appointments.

“The largest reason why this even exists is because we lost relationship with our patients,” said Dr. T. Scott McMurry, who opened a direct primary care practice in Kona in 2023. “The way the insurance model has changed care over the years has turned doctors into machines conducting 8- to 15-minute patient visits. But when you pull out this middle man of insurance that for so long has put so many carrots and sticks and barriers between doctors and patients, everything changes.”

Doctors who practice direct primary care report higher levels of career satisfaction and less burnout, results that could keep Hawai‘i doctors practicing longer. However, such practices typically see far fewer patients — 400 on average — since the structure incentivizes more personalized, in-depth care. Recent surveys estimate that the average primary care doctor working in a traditional practice sees between 2,300 and 2,900 patients.

The model, if widely adopted, could lessen Hawai‘i’s dire shortage of primary care doctors — or make things worse.

“If it allows doctors to have better lives and improves care for patients, I’m all for it,” said Kelley Withy, a physician and researcher at the University of Hawaiʻi’s John A. Burns School of Medicine. “But I’m concerned that we might be needing a lot more doctors.”

There are 12,688 licensed physicians in Hawaiʻi but the number of full-time active physicians is just over 3,000. Researchers at the UH medical school estimate that the state needs another 833 doctors, including 178 primary care physicians, to meet patient demand.

Dr. Curtis Takemoto-Gentile, who converted his Honolulu practice to direct primary care on Jan. 1, represents both the hope that the model could boost the state’s medical workforce and the worry that it might further erode it.

The 72-year-old doctor said he was so burned out working in traditional insurance-based medicine that he nearly closed his practice. A shift to the direct primary care model prevented him from retiring, which would have left all 2,500 of his former patients scrambling to find a new physician. But since the model has allowed him to downsize his patient load to 300, most of the people who received care from him now find themselves seeking a new doctor.

Handling fewer patients has granted Curtis the time and flexibility to offer home visits to seniors, homebound patients or people with limited mobility.

There are more than 2,875 direct primary care practices across the United States. In Hawai‘i, there are seven such practices, on O‘ahu, Kaua‘i and the Big Island. Three Honolulu physicians adopted the model in the last five months, one of whom moved to Hawai‘i to start up a primary care practice. Another doctor is in the process of relocating to the state for a job in direct primary care.

The model originated on the U.S. mainland in the late 1990s but did not appear in Hawai‘i until 2016.

Dr. Donna Mayeda, who moved to O‘ahu from California last year to establish a direct primary care practice, said she considered shifting to a new career in medical consulting before deciding to step outside of the insurance model.

“You’re only caring for a tenth of the patients that a traditional physician would see but I could see myself doing this until I retire,” Mayeda, a 38-year-old mother of three, said. “Every day when I was in the traditional system, I was questioning how many more months I could do this for, and I wasn’t alone in that sentiment.”

Mayeda’s patients include public school teachers, single-income families, first responders, self-employed business owners and venture capitalists. As she builds her patient base, she said her goal is to offer adjusted rates for lower-income patients.

On Kaua‘i, Dr. Clara Krebs, who operates the island’s only direct primary care practice, said her monthly rate runs between $250 and $350. Although her goal is to charge patients a fee comparable to a typical cell phone bill, she said her prices reflect the high cost of commercial real estate.

Her fees, the highest in the state, have not deterred patients. She limits her practice to about 200 patients — far fewer than the 2,500 patients she handled when she worked at a medical clinic run by Hawai‘i Pacific Health. Another 250 people are on a waitlist to join her practice.

“People want to pay to not be in a Taco Bell drive-thru of medicine,” Krebs said. “Their health is worth it to them. The sad thing is I can’t do this for everyone that wants it.”

This summer Krebs plans to double her clinic’s patient base with the addition of a second physician, whom she recruited from San Francisco. That doctor, she said, will charge a lower membership fee.

Krebs said she personally earns less pay now than she did working in the insurance-based model, although most doctors interviewed for this story said they earn more or expect to earn more when they finish building their patient base.

But Krebs cites other benefits. The shift to direct primary care has helped her achieve better work-life balance, a greater sense of occupational satisfaction and, she claims, more personalized care and better health outcomes for her patients. She said she has helped some senior patients achieve their desire to die at home instead of in a nursing home or hospital.

“I will never go back to insurance-based care,” she said, “and my patients feel the same.”

Civil Beat interviewed more than a dozen doctors and patients about their experiences delivering or receiving health care in a direct primary care practice.

Patients who’ve joined direct primary care practices cite frustrations with the traditional insurance-based model, such as rushed appointments, long appointment wait times and unpredictable medical bills.

Others choose to follow a longtime doctor who switches to the out-of-pocket fee structure out of a sense of loyalty.

“I’m like everybody else, I don’t want to pay any more money for everything,” Maureen Harnisch, who is in her 60s and lives in Kaimuki, said of her decision to pay her doctor of 17 years a $200 monthly fee after he stopped accepting her insurance in January. “But life is about choices. I think my doctor is a superior doctor and that has not been my experience everyplace else.”

Harnisch, who relies on Medicare for health coverage, said she canceled her subscriptions to an identity theft protection service and a couple of TV and movie streaming services to make room in her budget.

New federal tax rules adopted this year allow patients to use pre-tax funds from a health savings account to pay for direct primary care fees that do not exceed $150 per individual or $300 for a family.

Although the vast majority of Hawai‘i’s 1.4 million residents have health insurance, the state’s medical workforce shortage, which is most severe among primary care physicians, means coverage doesn’t necessarily equal care.

Many patients wait weeks or even months to get a doctor’s appointment. This can lead people to seek more costly care from urgent care clinics or hospital emergency departments.

The doctor shortage is exacerbated by the state’s rural geography, high cost of living and low reimbursement rates from insurance companies. Medicaid reimbursement rates in Hawai‘i are sometimes so low as to barely cover the cost of care.

Dr. Curtis Takemoto-Gentile said that in the insurance-based model there is sometimes a financial disincentive to offer patients more comprehensive care because insurance companies often do not reimburse physicians for stitching, bandages, gauze and other basic supplies. Insurance reimbursed him a flat office visit fee regardless of its duration or the number of procedures he performed.

“My internal clock was always saying? ‘OK, it’s 12 minutes into this visit, I need to wrap this up because in order to stay in business we need to see more patients.’”

After converting his practice to direct primary care, he said he now sees 4 to 10 patients a day instead of 20 to 25.

The traditional insurance-based model can also be frustrating for patients.

“It felt like I was just a number,” Rachel Hughes, a 42-year-old mother of two, said of her experience in the medical system before she joined a direct primary care practice in Kona.

Hughes said she finds value in the fast access that the direct primary care model grants her to a doctor who knows her by name and takes the time to learn about her family health history and lifestyle.

“I think of it like a gym membership,” she said. “We don’t have a lot of money but I have peace of mind that everything’s covered and the doctor’s just a text message away.”

When she sought help with intense, chronic headaches, Hughes said her doctor performed a series of interventions, including a manual adjustment and trigger point injections, during a single, lengthy appointment.

“What I liked the most about it is he said, ‘Let’s find what’s the source — is it stress, are these really just tension headaches and not really migraines?’” Hughes said. “Other doctors just wanted to write me a prescription.”

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“ Hawaiʻi’s Changing Economy ” is supported by a grant from the Hawaiʻi Community Foundation as part of its work to build equity for all through the CHANGE Framework.

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This story was originally published by Honolulu Civil Beat and distributed through a partnership with The Associated Press.