The Primary Care Capacity Test A Policy Framework for Measuring Real Access Before Major Payment, Network, or Merger Changes in Hawaiʻi

Executive Summary Hawaiʻi should not approve major payment, contract, network, or merger-related changes unless those changes preserve or improve real primary care capacity. The state’s access problem

HHTF Staff · 2026-06-01

Executive Summary

Hawaiʻi should not approve major payment, contract, network, or merger-related changes unless those changes preserve or improve real primary care capacity. The state’s access problem cannot be measured only through claims, utilization, or provider directories. Patients experience access as an appointment they can actually get, from a clinician who is actually available, in a place they can reasonably reach.

This brief proposes the Primary Care Capacity Test as a practical standard for regulators, lawmakers, health plans, physician organizations, and the public. The test asks four questions: Can patients get care? Can practices stay open? Is the reported network real? Is there a correction process before patients and practices are harmed?

The test should apply to major health care restructuring in Hawaiʻi, including payment model changes, network adequacy filings, value-based care arrangements, ACO/MSO/CIN development, and the proposed HMSA-HPH One Health structure. Before Hawaiʻi accepts promises of coordination, efficiency, or cost control, it should require proof that patients will have real access to primary care.

The Problem

Hawaiʻi’s current debate over HMSA’s payment changes is often framed around a 60-day implementation timeline. That timeline matters. Physicians and practices cannot safely reorganize staffing, billing systems, patient access, and practice operations without complete written terms, fee schedules, rules, and operational guidance.

But the timeline is not the whole problem. The deeper issue is whether major payment and network changes will preserve the primary care capacity patients need.

Primary care is where chronic disease is managed, prevention occurs, medications are reconciled, specialist referrals are organized, and patients enter the health system before problems become emergencies. If primary care practices close, reduce services, stop accepting new patients, or leave insurance networks because payment is inadequate or administrative burden is unsustainable, costs do not disappear. They move to urgent care, emergency departments, specialists, hospitals, families, and ultimately premiums.

A payment model can look administratively coherent while weakening the clinical infrastructure patients depend on. A network can look adequate on paper while patients cannot find an available clinician. A utilization model can show low use while patients are delaying care or giving up.

Hawaiʻi needs a standard that measures real access before approving major changes.

Core Principle: Do Not Base Future Need on Current Scarcity

Health care need should not be projected from current utilization when current utilization is constrained by lack of access.

If patients cannot get appointments, if panels are closed, if physicians are leaving practice, if reimbursement does not cover the cost of care, or if patients must travel long distances for basic services, then current utilization is not a reliable measure of demand. It may be a measure of unmet need.

This matters for payment reform and network oversight. A low-use system can be misread as an efficient system when it is actually an undercapacity system. Fewer visits may mean better prevention in some settings. In an access-constrained setting, fewer visits may mean delayed care, unavailable appointments, longer waits, or care shifted to higher-cost settings.

Hawaiʻi should not allow payment models, network filings, or merger proposals to treat current scarcity as an acceptable baseline.

The Primary Care Capacity Test

The Primary Care Capacity Test asks whether a proposed payment, contract, network, or organizational change will preserve or improve real primary care access.

The test has four parts.

1. Can Patients Get Care?

A proposal should show that patients can obtain timely primary care from active clinicians who are actually available.

This requires more than a provider directory. It should include evidence of open panels, appointment availability, reasonable wait times, island-level access, and the ability of patients to reach care without unreasonable travel or delay.

Statewide averages are not enough. Access must be measured by island, county, payer line, and patient population. A model that works in urban Honolulu may not work in Kaʻū, Kona, Hilo, Molokaʻi, Lānaʻi, Maui, or Kauaʻi.

2. Can Practices Stay Open?

A network is not adequate if its payment structure makes participation financially unsustainable.

Payment levels must be sufficient to keep primary care practices open, especially independent, rural, pediatric, and neighbor-island practices. Primary care payment is not only a physician compensation issue. It is an access issue for patients.

A primary care spending target or floor should be part of the standard. A defined share of total medical expenditures should support frontline primary care, rather than relying on temporary increases to an inadequate base. Hawaiʻi should know how much health care spending reaches primary care and whether that investment is sufficient to maintain access.

3. Is the Network Real?

A paper network is not the same thing as care.

A health plan may list physicians in a directory, but patients experience access as an appointment they can actually get. A listed clinician should not count as available if the clinician is retired, misclassified, unreachable, not accepting new patients, unavailable for months, no longer practicing at that location, or unable to take patients under that payer line.

Network adequacy should be independently verified. Provider directory accuracy, closed panels, appointment wait times, and island-level access should be measured directly. Hawaiʻi should not rely only on self-reported access when patients are already struggling to find care.

4. Is There a Correction Process Before Harm Occurs?

Major payment and network changes should not depend on informal consultation after decisions have already been made.

Physicians and practices need a formal process to identify payment, access, attribution, administrative, and network problems before those problems damage patient care. The process should include written responses, defined timelines, correction pathways, and accountability when problems are confirmed.

Clinician governance should be meaningful. Practicing physicians, independent practices, rural clinicians, pediatric clinicians, APRNs providing primary care, and neighbor-island providers should have a formal role in evaluating changes that affect access.

Application to Current Hawaiʻi Decisions

The Primary Care Capacity Test should guide the current HMSA payment transition. A delay in implementation is necessary, but delay alone is not sufficient. Any revised timeline should be tied to written safeguards that protect real access.

Before major payment changes take effect, physicians should have complete written terms, fee schedules, rules, operational guidance, and adequate time to evaluate the effect on practice viability. Patients should not lose access because practices are forced to reorganize around incomplete information.

The test should also guide review of broader health care restructuring proposals, including the proposed HMSA-HPH One Health structure. The question is not whether coordination sounds attractive. Hawaiʻi needs better coordination. The question is whether a larger health care organization or new payment model will improve access to care or simply reorganize payment, ownership, attribution, and reporting.

Coordination without primary care capacity will not solve Hawaiʻi’s access crisis. Larger organizations and value-based care structures cannot substitute for the clinical front door patients need.

Policy Recommendations

Hawaiʻi should adopt the Primary Care Capacity Test as a review framework for major payment, network, and organizational changes.

Regulators, lawmakers, and health care organizations should require evidence that any major change will preserve or improve real primary care capacity before implementation.

That evidence should include active clinician counts, open panels, appointment wait times, island-level access, payer-line access, directory accuracy, rural and neighbor-island capacity, and payment adequacy.

Hawaiʻi should establish a primary care spending target or floor to ensure that a meaningful share of total medical expenditures reaches frontline primary care.

Network adequacy should be independently audited rather than accepted through self-reported directories alone.

Major payment changes should require complete written terms, adequate notice, and a defined review period before implementation.

Administrative burden should be reduced, including prior authorization and quality-reporting requirements that consume clinical resources without clearly improving patient care.

Quality measurement should focus on a small number of clinically meaningful measures. Payment reform should make good care easier to deliver, not harder to document.

Future payment models should be developed with practicing clinicians, HMA, HAFP, HAPN, SHPDA, AHEC, rural practices, independent practices, and patient access experts at the table.

Conclusion

Hawaiʻi should not wait for more practices to close before asking whether patients have real access. Any major health care payment, network, or merger-related change should be required to pass the Primary Care Capacity Test before it moves forward.

The immediate question is not whether Hawaiʻi should use fee-for-service, capitation, hybrid payment, or another model. The question is whether any model can support timely primary care from practices that can afford to remain open.

Before Hawaiʻi approves a bigger health care system, it should require proof that patients can reach the one they already have.