By Dr. David Khorram

SAIPAN, CNMI (Saipan Tribune, July 15) – I've always said that our healthcare system in the CNMI is among the best in the region, and that the overall quality of physicians here is as high as in other rural communities anywhere in the United States. Yet our population is medically underserved.

The resources for care, though good, are limited. There are not enough doctors to serve our population. The public health care facilities are often short of supplies and specialists. On the operating room wall there hangs a quotation from Dr. Howard Tait, who served as the CNMI's orthopedic surgeon for many years. Speaking to other surgeons, he said, "If you have to have everything you need to do the case, you probably shouldn't be here."

Strangely, these are the very reasons that many of us choose to practice medicine here. We get personal satisfaction from making a difference to the people we serve, and we learn from the challenges of not having everything we need.

The U.S. Department of Health and Human Services routinely evaluates the access to care in all U.S. jurisdictions and gives each geographic area a Health Professional Shortage Area (HPSA) score. This HPSA score is an indication of how badly doctors are needed in an area. The scoring system takes into account such factors as the number of doctors available for the population, and the travel times to the nearest available source of care. The higher the score, the worse off a region is, and the more badly doctors are needed. An HPSA score of 25 is bad, 1 is great.

How do you think the CNMI ranks on this list? Well, it's pretty bad; in fact, among the worse. For non-metropolitan areas in Region IX, the highest shortage award goes to the FSM, with an HPSA score of 25. There is no other area in the entire U.S. with a greater need for doctors. This is followed by a few Indian Reservations in Arizona, California and Nevada that have HPSA scores between 21 and 19. Next comes American Samoa with an HPSA score of 20. And then, the CNMI with an HPSA score of 18.

An HPSA score of 18 is bad. It is an indication that despite having one of the best hospitals in the region and having great doctors on the island, we are among the most underserved areas in the entire country. Guam fares much better than we do, with a score of 8. Many Indian Reservations have better HPSA scores and less of a doctor shortage than we have.

Areas that have doctor shortages typically do everything possible to bring in more doctors. There are tremendous challenges in bringing in new doctors to the CNMI. After all, the area is underserved for a reason. If it were considered a great place to practice medicine, there wouldn't be a shortage in the first place. This is one of the reasons that our public facility is constantly short of doctors and specialists. There has to be a compelling reason for people to move halfway across the world, to an unknown land, far from their families, and take a pay cut to work under challenging circumstances.

In my case, I had always wanted to work in an underserved area and to feel like I was making a real difference to the people I served. When I arrived in the CNMI 12 years ago as a government employee, I thoroughly enjoyed establishing the first eye care services at CHC. It was a challenge, and I was able to make a big difference quickly. We saved the government hundreds of thousands of dollars in referral costs, and I had the privilege of making life better for my patients. After five years at CHC, my wife and I decided to make the CNMI home and realized that this would be difficult to do while working for the government. Each year there were questions of whether or not funding would be available for my position and whether or not my contract could be renewed. I had also reached the limit of what I could build under the government system. I came from one of the best training centers in the U.S., and I wanted to bring in the best eye care technologies to the CNMI. The emphasis of CHC was rightfully in providing primary care to as many people as possible with the limited resources available, so it just wasn't possible to spend money on the more advanced technologies I was requesting. For these reasons, and with the enthusiastic support and encouragement of the administration, I entered the private sector. And this is where I believe the future of improving health care in the CNMI lies. We will always need a government-supported hospital. But one of the keys to addressing our poor HPSA score and building a stable medical community is to encourage the development of private medical practices.

Most of us in private practice came to the CNMI as government employees. Dr. Tony Stearn's venture into private medicine resulted in the establishment of FHP (now PacifiCare), and more recently of Marianas Medical Center. Dr. Hocog and Dr. Aldan built Saipan Health Clinic. Dr. Ahmad Al-Alou established Pacific Medical Center. Tony Glad built Island Medical Center. And most recently, Dr. Norma Ada has opened Medical Associates of the Pacific. Together, these practices, along with my own, remove the burden of some 60,000-76,000 office visits from the shoulders of the government facility each year. Private practices provide stability and continuity of care. The average number of years that each of the physicians in private practice has served in the CNMI is somewhere between 10-15 years. We put down roots. Those of us in specialty care like myself provide support to other physicians, like those in the emergency room, when complex cases arise. Private medical offices are more likely to invest in the most advanced technologies, which raise the level of care for the whole population. It was Dr. Al-Alou at PMC who had the vision and the means to bring the first CT scanner into the CNMI. Marianas Eye Institute brought in technologies that most eye care practices in the U.S. mainland don't even have. Private medicine raises the level of care available to you.

I share these benefits because I believe that stimulating the development of private medical practices can be more actively pursued in the CNMI. In Guam, we see that the entire medical care system, like that in every other developed jurisdiction in the United States, is built upon a strong and healthy private practice model. We need to actively attract doctors into private practice. As a community and a government we may wish to consider the big picture of healthcare, and of our severe physician shortage, and consider which legislation, policies and regulations-which decisions-will move us closer to addressing our doctor shortage, and which will take us further away. Quality healthcare for the greatest number of people is a guiding principle that can serve as a touchstone when considering the impact of various decisions.

David Khorram, M.D., is a board certified ophthalmologist, and director of Marianas Eye Institute.

July 15, 2005

Saipan Tribune

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