Kaiser Permanente Hawaii plans to eliminate nearly one-quarter of its clinic registered nurses, replacing some of them with lower-skilled licensed practical nurses and medical assistants.

The state’s largest health maintenance organization is proposing to cut at least 47 registered nurses in primary care positions at some of its 18 clinics statewide as part of an extensive "redesign," Kaiser said this month in a memo obtained by the Star-Advertiser.

The HMO boosted rates Jan. 1 by 5.3 percent for 155,000 employer-sponsored plan members and 9.7 percent for roughly 14,400 individuals, in addition to raising monthly premiums for 8,950 seniors on Medicare. Kaiser offered contract buyouts to 280 nurses late last year and now plans to issue layoff notices Feb. 4, according to nurses familiar with the situation.

The company said in the memo to the Hawaii Nurses Association that it also will close the Hono­lulu Urgent Care Center, which has an average volume of 30 patients per day, and cut operating hours at the Moana­lua Ambulatory Treatment Center from 12 hours, seven days a week, to 10 hours, six days a week.

Nurses who asked not to be identified said the cuts are being driven by Kaiser’s fear of lower reimbursements in 2014 as a result of the federal Affordable Care Act.

About 195 registered nurses work in the clinics, and roughly 850 work in the organization. RNs at Moana­lua Medical Center, Kaiser’s sole hospital on Oahu, are not affected. RNs can apply for 31 openings throughout the organization, according to the nurses.

Both Kaiser and the Hawaii Nurses Association, which have a so-called "labor management partnership" that puts physicians, managers and union members in unit-based teams to collaboratively solve problems, have been tight-lipped about the cost-cutting measures and workforce reductions. Kaiser declined multiple requests for comment, while union president Joan Craft did not return calls or emails.

Despite the labor management partnership, union nurses complain that there had been virtually no communication from their employer or the union up until a few weeks ago.

Kaiser RNs wrote in a letter distributed to the Hawaii Nurses Association on Friday that they strongly disagree with the union’s position of accepting the redesign plan "initiated solely by Kaiser management" and are urging the union not to finalize an agreement until members are given an opportunity to meet with the organization.

"This plan jeopardizes patient safety and will impact quality of care and patient satisfaction," the nurses said in the statement. "This is a plan that has had no input from the frontline worker that knows the demands of clinic operations."

John Borsos, secretary-treasurer of the National Union of Healthcare Workers, representing 4,000 health care workers at Kaiser in California, said the company has notified some 1,000 mainland workers — none of whom is a member of his union — of layoffs in 2013.

"It’s outrageous," he said. "Kaiser’s made $8.2 billion (nationally) in the last three years. There’s absolutely no justification for it. They’re experiencing record profits and they’re laying people off."

Locally, Kaiser reported a profit of $2.3 million through the first nine months of 2012, the latest data available. That follows a $4.3 million profit in 2011.

Kaiser, which has about 4,400 employees at the Moana­lua Medical Center and Clinic and 18 clinics statewide, eliminated 35 union and management positions in October in an effort to streamline operations.

Kaiser said late last year that voluntary buyout letters were sent to nurses in an effort to redesign the way health care is delivered and adjust staffing levels in an increasingly competitive market to ensure the HMO had the "right workforce to be nimble in the marketplace." About 25 nurses accepted the buyouts.

Registered nurse Garry Johnson, a University of Northern California nursing professor who was on Oahu last week to pre­sent a lecture for critical care nurses, said health care organizations across the country are replacing licensed practical nurses with registered nurses — the opposite of what Kaiser is doing — because of their broader scope of practice.

"The RN is more trained to intervene with more acute-care patients," he said. "It’s a big safety concern. It’s really regressive for Hawaii and this organization to be planning to move away from that when the movement is completely in the other direction."

Registered nurses have as much as four years of education, compared with 18 months for licensed practical nurses and less than a year of training for medical assistants, he said.

Licensed practical nurses and medical assistants aren’t trained for RN duties such as administering intravenous medications or assessing ailments, and are paid about half the salary of a typical RN, who makes $50 an hour on average in Hawaii.

Johnson pointed to a recent study, "Failure to Rescue," by Linda Aiken, that describes the relationship between nurses’ level of education and survival rates and patient outcomes.

"The bottom line for her study is nurses with lower levels of education were not recognizing that patients were actually deteriorating," he said. "The more educated the nurse, the more the patients were likely to survive."

He added that California used the study to enforce nurse-to-patient ratios.

Eliminating RNs eventually will cost the system more, Johnson added.

"At the end of the day, they don’t end up saving money," he said. "When patients go south, they start to deteriorate and become sicker, and not all of them are going to die. Some of them will end up in the (intensive care unit) or higher levels of care … and that all costs money."

Kalihi resident Aukuso Pele­foti said he fears the changes will jeopardize care for his children, ranging in age from 8 to 13.

"That means the quality of care is not going to be the same as before," he said. "It doesn’t make sense. If they’re trying to cut costs, maybe cut their hours, but don’t replace the quality of staff. My kids have been at Kaiser since they were babies. If the quality of care is going to go down, that means we’ll have to look someplace else. One thing is for sure: If that’s the case, goodbye, Kaiser."