Ok - Hawai'i. There was a study about 5 years ago across all medical specialties - on average, there were 3 docs for every 4 jobs in HI - there are not enough plastic surgeons and dermatologists in HI, believe it or not. However, there was one - and only one - outlier. EM was staffed at 104%, or 26 docs for every 25 jobs. That means a LOT of people working part time. However, when I was looking after my hospital shut down, the only places hiring were places I would NOT work - and, when you have many available workers, and people don't want to come to YOUR shop, that means you have problems.
Pay is abysmal for doctors in HI. For procedural specialties, they say expect 1/3 to 1/4 as much as you would make on the mainland. I made $100/hr as an IC. Granted, it was easy work, but that's it. Jobs on O'ahu range from $90-$120/hr. Democratic groups are none. I was part of a new one, which was started after they spun off from Schumacher. The founding partners were some prima donnas, and they were somewhat predatory. The group went under when the 2 hospitals in the system closed down in 2011. One hospital has been remodeled and is going to be an outpatient thing - no ED, no ORs, and no inpatient. The other finally - finally - is going to reopen, now staffed by the Queen's Medical Center.
Queen's is the flagship of medicine in the Pacific. After transplant left my hospital, it is now at QMC, and Honolulu is the only place in the Pacific where you can get a kidney or heart. The ED is a sweatshop.
The majority of ED jobs are hospital employed. However, EMP is there (Pali Momi and Kapi'olani), and EmCare took over Maui Memorial Medical Center (after being at my hospital years ago, and being bumped by Schumacher). There is a group on the windward side, which also covers the big island. Even after asking, I don't know their model. The one thing I was told, all around, though, was that I didn't want to work there. Back in 2007, when I first checked into it, they were who I found online. I shot them an email with questions, and the person got back to me asking if I could work next month. I said I wasn't even licensed in the state yet.
Outer islands are small hospitals, because no one lives there. There are 7000 people on Moloka'i - there aren't even any streetlights - only stop signs! There are 3000 on Lana'i (the island that Larry Ellison of Oracle bought), and Ni'ihau has 130 people and no hospital. Kaua'i, with 58K people, has Wilcox Memorial, which is part of Straub.
Back to O'ahu - main employers are Queen's, Kaiser, and Straub Healthcare - but the Straub Healthcare network is Straub, Pali Momi, Kapi'olani (which is the women's and children's hospital, and has an EM person always working for the vag bleeders and the homeless that come in), and Wilcox. As such, the models differ. In 2010, for people on the Straub "partnership track" (ie, planning to make a career, instead of just being casual/part time, but no actual ownership), they were paying $75/hr. Yes, you read that correctly. And, Kaiser is gold? I don't know - a classmate from med school was faculty there, and he left to go to Pali Momi (interesting note - it is "Pali Momi at Pearl Ridge" - with "pali" meaning "cliff" or "ridge", and "momi" is the Hawai'ian pearl - so it is "Pearl Ridge at Pearl Ridge" - like "Manos, the Hands of Fate").
The big problem in HI that insurance companies suppress the pay - between HMSA (BC/BS in HI) and Kaiser, the money is kept way down. I mean, what are groups going to do? They say "X", and HMSA and Kaiser say "go to another hospital". However, that is where the perfect storm of Maui enters. First, Maui Memorial Medical Center is the ONLY hospital on Maui - you can't tell the patients to go somewhere else. There are about 100K people on Maui, but there is a higher number of rich folks among them. What this means is that the Maui guys went out of network with all plans, which means they are making mainland-style money. But, "wait", you say! Insurance won't pay out of network rates. But, if you (the patient) are rich, you have sway, and Kaiser and HMSA can't tell you to "suck it", and they can't tell you to go to another hospital. So, it's the "perfect storm" - the triple play of lifestyle, location, and pay. You know the way it has been said you can pick two? Well, that is one of those rarities with all 3, and, like the Denver group about which I heard that has not had a doc leave in 9 years, people don't leave those jobs. Hell, I still have the pager number on my computer desktop of the guy who does (or did) the hiring at Maui - as he told me, "even if we like you, I can only give you 1 shift a month, maybe - it could be 3 or 4 years before a position opens". As for the medical director (that post above mine posted while I was composing here), that's not for everyone - it's not like someone with mainland admin experience can cruise in and do the same thing there that they did back on the mainland. I strongly suspect that the spot will be filled by someone from the islands.
A last word regarding that - for EM, I knew only one native Hawai'ian guy - college in HI, went to med school and residency on the mainland (in flyover country - seriously), and came back. The "native" doctors are mostly Chinese descendants (but 3rd or better generation American). After that, there are the Japanese natives. There are two guys that work at Kapi'olani in the Peds ED named "Inaba" - I don't know if they are related, and I didn't get to ask one if he was related to Carrie Ann Inaba (from "Dancing With The Stars", who went to the Punahou School). However, there are more native Hawai'ians (or part native people/people with native blood) in primary care.
