Dear Maui Department of Health  and Hawaii Department of Health, Office of the Mayor, Maui City Council and Maui Government, Hawaii State Government, Hawaii State Legislators, Maui Health System Board, Maui Memorial Medical Center Medical Executive Staff and Medical Staff and Hawaii Residents, 

Here in Maui, we have a small 200+ bed hospital. Like all workplaces, it has its workplace issues and politics, so why should you care about its workplace issues and the politics that go on behind closed doors and in the offices of this hospital? Well, because it is the only hospital on Maui and it serves three of our islands.  About 50,000 of your relatives and my relatives visit its Emergency Department every year. It has about 73,000 hospital days of our friends and loved ones in there fighting for their lives. They are fighting to come out of it alive with the help of its amazing physicians, nurses, ancillary staff, and administration. AND IT IS OUR ONLY OPTION. IT IS OUR ONLY HOSPITAL, so you should care what happens in the workplace here and the politics here. You should care because it may mean your or my or our relative's life or death.

For the past 6-7 years, the state has given the contract to run the hospital to Kaiser Foundation Hospitals (this is a completely separate entity from the Kaiser Permanente Medical Group). This entity is a nonprofit that only runs hospitals. They don't hire and fire doctors but give contracts to them. Kaiser Foundation Hospitals have been given by our state the contract to run the hospital for  years. For the first 5 years of their business, they have received over $ 50 million in state subsidies to run this private business. No other business in Maui has that much state subsidy to run as a private entity, so basically, it is still partly owned by taxpayers. It is a public-funded entity run as a private nonprofit with profits forked over to its private investors and banks in California.

When I came to the island in 2018, I was excited. I thought it was such a great place to work. Most everyone was very happy working here. The ED physicians and interventional radiologists were responsive and the nurses were very helpful. There were local subspecialists. I thought it was a diamond in the rough. It had great people, it just needed help getting solvent because, like all government-run places, it didn't know how to bill and chase after money to get it in the black and not go bankrupt. And you need an army and very skilled people to do the coding, billing, and chasing after insurance because the insurance companies here in Hawaii play so many games.

But as the new Kaiser Foundation Hospitals administration headed by the CEO Mike Rembis started to change things around, the place started to get much worse (although the hallways are repainted and look new every two years). Before the pandemic, Hospital CEO Mike Rembis signed the contract to the Emergency Department to Emergent Medical Associates (“EMA”)  run by his friend Dr. Lee Wiess. It is my understanding that EMA is a private contract management group. See https://www.ema.us/corporate_overview.html  Here's a little something about private  groups in healthcare:

 "The profit-making goals of private equity (and in my opinion private investors in general) are, in many ways, at odds with the needs of patients and the rules of government-financed health care programs. In fact, since 2013, private equity-owned health care companies have paid more than $500 million to settle claims of overcharging government health care programs. Though there is always a profit motive when private investors acquire a company, private equity firms in the realm of health care should be viewed with skepticism. In this industry, the “product” at issue is a person’s health, not a computer or a bicycle pump. The business model of these companies — its goals, structure, and the operation of portfolio companies — combine to incentivize short-term profits at the expense of all other considerations. The result is that patients, communities, and even entire health care systems can suffer." (https://www.statnews.com/.../private-equity-health-care.../

It was reported to me from anonymous sources that right away the ED physicians' incentives were cut back. As reported, they became effectively hourly workers instead of being in a democratically-run department (which studies and literature have proven to have the best clinical outcome) as was promised to the hospital. Also, the group promised to lower the cost of ED care to the population, but it is not clear to me that these costs have gone down.. Not only that, it is reported by anonymous ED physicians, that the group brought in advanced practice nurse practitioners to help with workload for ED physicians.    the company didn't give ED physicians enough time for direct supervision and overseeing patients AND expected them to sign  charts without sufficient clinical time to see each patient.   It was reported in the Star Advertiser on August 4 that a group of emergency room doctors sent an anonymous letter to the Hospital’s Board of Directors alleging that EMA “has employed underqualified nurses to treat patients in the ER, while fraudulently billing their care at full physician rates.”  In the same article, EMA’s president said this letter is “rife with inaccuracies.”  I call on the state, the state auditor, Medicare authorities, and Maui County to get to the bottom of these allegations and investigate.  I also call on the residents of Maui who have been treated at the Emergency Department to request from their insurances itemized break down on what you paid and what was paid in your behalf by your insurance company and request for your medical records to ascertain the providers and physicians who treated you in order to help to investigate it.  This is an actionable item for the community to do to help this petition.  If you are willing, you can send them to me or write them in the comments (without disclosing your diagnoses or any details about your medical care). We deserve the truth.

Last year, there was an ED physician suicide. This physician was someone I knew and worked with. Prior to his death, I personally witnessed how changes in his working conditions negatively affected him.  Early this year, in the middle of the pandemic, with the ED hold time (meaning patients stuck in the ED waiting for a bed) lasting for days, this ED company cut the ED physician's salary by almost half. In. A. Pandemic. Imagine having a home, kids, and a community here and being told-Oh, we know we are still in a pandemic. Yes, there's 9% inflation.  You are busier than ever and there's less manpower than ever, but by the way, we are cutting your pay in half. This is a very high cost of living area. In one month, multiple physicians and advanced practice nurses left, creating a shortage of physicians in this ED such that they are relying on travelers to come in for a week to two weeks at a time. There are new physicians every couple of weeks learning or relearning the system. When healthcare workers aren’t connected to their communities, there’s little incentive or room for making or suggesting long-term improvements in the system.  And even if the traveler physicians do suggest improvements, there’s no one to hold the Hospital administration and this ED contract management company to these suggested changes for the long-term because they’ll be gone.   There have been travelers for interventional radiology when they had two interventional radiologists willing to work at this Hospital who are now working elsewhere and while one travels for work weekly from his home in Maui to another island in Hawaii to continue his beloved clinical work. Some days, the Hospital  just doesn't have GI or IR or urology, or other subspecialists available. Its excuse that there is a worker shortage doesn't apply here because many of the people that quit still live here- they just work elsewhere. Some physicians would love to have stayed in Maui but found no support here.  Instead, they found quite the opposite, a toxic work environment as reported to me.

Despite their recent awards in the news, how are you affected? Well, it means delayed care for GI bleeds or more transfers to Oahu where you don't have a family member. It means that someone is learning the system over again every few weeks instead of just focusing on you and your illness, and guess what happens there? Increase risk for delays of care and errors=patient harm.

It was reported to me from multiple sources that there was recently an unofficial meeting and a vote (five out of five present) among the Board of Directors of Maui Health System to investigate Hospital CEO Mike Rembis for financial conflicts of interests relating to the ED group, but during the following board meeting, there was a lawyer present and the need to investigate Mr. Rembis’ conflict of interests were discussed and then was voted down.

In the same half of the year, a devoted vascular surgeon who hardly took a vacation, and whose life was in the operating room day in and day out, quit because he just couldn't get the support he needed from the Hospital. In the same half of the year, the Hospital almost lost a surgical oncologist for varying issues relating to administration, but I gave him my lawyer's contact to negotiate for him, and he is now staying. The permanent GI doctors quit at the same time. Personally, due to the lack of available subspecialists, it is a hit and miss on my surgical calls if I'll be practicing 3rd world medicine with 1st world liabilities that day. This Hospital administration has also tried to separate itself from any liabilities by contracting out to private companies and private practice doctors like myself. 

Let's go back to the issues with the ED department. Earlier in the year, there were anonymous complaints to the Board of Directors of the Hospital that the ED group hasn't held any true real democratic elections, so the Board ordered the company EMA to hold democratic elections. An anonymous source forwarded me this letter, which was already sent to over 75 physicians (Medical Executive Committee members, ED physicians, and administration),  from Dr. David Williams (Vice-Chair Elect Department of Emergency Medicine MHS/MMMC, EMS Medical Director, State of Hawaii, DOH, Maui County, Associate Trauma Medical Director, Maui Health System). Dr. David Williams writes: 

"On June 3rd, 2022, the Department of Emergency Medicine (DEM) held our first, free, fair, and democratic election for the position of Vice-Chair. Following my election as VC, by an overwhelming majority of ED physician votes, ratification was expected at the Maui Health System (MHS) Medical Executive Committee (MEC) meeting on June 14, 2022, as a formality."

Instead, the confirmation was stalled by a request to investigate Dr. David Williams for alleged unprofessional behavior. There are text exchanges among the ED company's former administration and nursing manager reporting that his record was clean. 

"There was a comprehensive and predatory review of my personnel file at MMMC that revealed a near decade-long pristine career, without evidence of a single complaint, not a single peer review case for practice improvement or bad outcomes, nor a single Unusual Occurrence Report (UOR)," writes Dr. David Williams. He writes, 

“The insinuations of impropriety directed at me, were and are baseless, malicious, and hostile, and I believe were made to derail the ratification of my fair election to Vice Chair. I trust that the full transcript, with these disturbing and disparaging remarks, will be made available during investigation into these matters...When a comprehensive and predatory review of my personnel file at MMMC revealed a near decade long pristine career, without evidence of a single complaint, not a single peer review case for practice improvement or bad outcomes, nor a single Unusual Occurrence Report (UOR), it is easy to imagine Dr. Ayasonanda’s desperation for some sort of “damning evidence” to put forth to the Committee. On June 22, the day prior to the MEC Executive Session Meeting, with pressure to deliver “something”, Dr. Ayasanonda began to conspire with "Hospital Admin" and Mr. Julius Montehermoso, MHS Emergency Department Nurse Manager/Supervisor via text message to illicit fraudulent, slanderous, and last-minute, charge nurse complaints and UORs against me. This smear campaign went to a “next level” when Mr. Montehermoso offered Maui taxpayer dollars (?!) in overtime pay to nurses willing to create these falsified complaints against me."

Dr. David Williams continues to write,

"On June 23rd, 2022, at the MEC Executive Session Meeting, the solicited, fabricated, and slanderous complaints – lies about me – were presented by MHS Attorney Mahina and Medical Staff Representatives, as valid complaints. These defamatory and false accusations have now rendered significant and irrevocable damage to my professional reputation and have disrupted my lawful right to work without the hindrance of a caustic and hostile work environment. (My EM colleagues have also suffered greatly under these hostilities. I need not remind everyone that we are a department which has recently suffered a physician suicide and five physician resignations last month as a result of this type of abusive leadership style)...The damning text message exchanges with the actors from the MHS Emergency Department at MMMC, leave little question of their intent to malign and raise deep legal and ethical concerns about their actions...On June 23rd, 2022, at the MEC Executive Session Meeting, the solicited, fabricated, and slanderous complaints – lies about me– were presented by MHS Attorney Mahina and Medical Staff Representatives, as valid complaints. These defamatory and false accusations have now rendered significant and irrevocable damage to my professional reputation and have disrupted my lawful right to work without the hindrance of a caustic and hostile work environment.  These actions have compromised the healthcare being delivered by MHS to the Maui community and we look forward to your prompt interventions."

Dr. David Williams’ position has now been ratified (after this petition went out to the community), but nevertheless there is very low morale in the Hospital and Emergency Department now and not only because of the pandemic, but because there's real toxicity there. Nurses, managers, and directors share experiences that have taken a great emotional toll on them.

By and large, the physicians, the medical groups, the nurses, and staff who I have spoken with would like to petition a change of Hospital administration and CEO, but they are fearful for their jobs because this is their home and this is the only hospital in which they can apply their lifesaving skills and expertise. We need help. We healthcare workers have shown up for the community during COVID, despite this hospital administration's early attempt to disallow us to mask up with N95s to protect ourselves in the hospital which only changed because of the public outcry early in the pandemic. (Do you remember?) We need you to show up for us again. We need you to sign a petition to help us, us who are crying and are enraged in silence,  in the ONLY hospital in Maui.

This petition asks and demands the Boards of Directors of the Maui Health System, the Mayor, the Maui City Council, and the State Representatives and the State Auditor to:

1) Investigate the allegations of billing fraud by EMA that were reported by the Star-Advertiser on August 4.

2) Demand that Hospital CEO Mike Rembis be investigated for potential conflicts of interest with the ED company EMA and demand his resignation

3) Demand the resignation of the actors involved in falsifying career-damaging accusations regarding Dr. David Williams

4) Demand that EMA be changed over to a completely different, truly, democratically-run ED group

5) Demand that Kaiser Foundation Hospitals provide Maui Memorial Medical Center long-term, Maui-based physicians and staff . Demand that they stop relying on travelers to provide critical physicians and subspecialists (or the state should revoke any support and the contract and find another company to run this hospital).

6) Investigate any Board of Directors of MHS with a conflict of interest with Mr. Mike Rembis or EMA

7) Demand that any future company managing the hospital takes profit from one department and with that profit help the less lucrative parts or specialties in the hospital so we can have comprehensive services and subspecialists available in all critical departments, i.e. demand that there's accountability/transparency in how much the EMA company gets from facility fees versus professional fees and have them justify any excess profits. As with how most hospitals work, you can't piecemeal the departments.  The surgical department,  the ED facility fees, trauma activations fees, and imaging departments are the lucrative parts of the hospitals that need to subsidize other parts of the hospital that don't make as much money, like the hospitalist groups or pediatrics departments, etc.

 

8) Support the community by committing to fundraise with us as we create the largest Patient Advocacy group Allied with Physicians, Nurses, and Healthcare workers in Maui so we can hire and recruit independent lawyers that will litigate these powerful companies. It is very hard to hire a lawyer in Maui to take on any of these big guys for any wrongdoing.

9) COMMUNITY PARTICIPATION NEEDED: I also call on the residents of Maui who have been treated at the Emergency Department to request from their insurances itemized break down on what you paid and what was paid in your behalf by your insurance company and request for your medical records to ascertain the providers and physicians who treated you in order to help to investigate it.  This is an actionable item for the community to do to help this petition.  If you are willing, you can send them to me or write them in the comments (without disclosing your diagnoses or any details about your medical care). We deserve the truth.

I can complain all day.  And I have.  I am tired.  When I was telling my MA who was born here in Maui (part Hawaiian, part Filipino, part Portuguese, full on amazing) about everything happening and how disheartening and tiring it is, she reminded me, "Yes, you've only been here 5 years.  Imagine your whole life and multiple generations of locals and our people here feeling that way about things not changing despite our struggles to be heard. We just don't get heard. These political games that go on at the top affect us in real ways. It's life and death for us because those wealthy transplants can afford Mayo clinic or Stanford or whatever mainland Center of Excellence when they get sick, but we are stuck here, and we are stuck with these money-hungry, ego-driven outsiders coming in here to lead, profit, and leave us in the same place or worse. Generations of that."

So I can't be tired and I can't be afraid. They will do the same to me as was apparently attempted against Dr. David Williams (who is now fired from his emergency physician job). They will invent something, despite my spotless record, to get rid of me here. But guess what, I'm not going out without a fight.

"I wanted you to see what real courage is, instead of getting the idea that courage is a man with a gun in his hand. It’s when you know you’re licked before you begin but you begin anyway and you see it through no matter what. You rarely win, but sometimes you do.” -Atticus Finch from my favorite book To Kill a Mockingbird.