Dean Ida, who lost both his legs to diabetes, is one of nearly 20 patients that Hawaii Medical Center is scrambling to relocate as the bankrupt hospital winds down operations early this month.

The 44-year-old double amputee, who requires specialized dialysis treatment four times a day, has lived at HMC’s Liliha campus for six years.

Long-term, chronically ill patients, many of whom have no way of paying for their expensive care, are a challenge for Hawaii’s health care system.

Many of them are on government insurance programs such as Medicaid, which pays 70 to 80 percent of the actual costs of care, according to Toby Clairmont, director of emergency services at the Healthcare Association of Hawaii, which represents hospitals statewide.

These patients "are always hard to place," Clairmont said. "They tend to be the ones who have been there for a while, either expended insurance or don’t have insurance and can’t find a doctor to care for them."

HMC, which decided just weeks ago to close the former St. Francis Medical Centers, expects to shutter its Liliha campus in the next few weeks after it relocates the last of its patients. HMC’s Ewa hospital closed on Wednesday and transferred its remaining patients to Liliha.

In recent years there were as many as 200 chronically ill patients inappropriately placed in more costly acute-care hospitals, while waiting for a long-term care bed to become available. They live in acute-care hospitals for months — sometimes years — because of inadequate long-term care services in Hawaii.

Long-term care facilities, such as the Leahi Hospital in Kaimuki, focus on patients who stay more than 25 days. Acute-care hospitals are for patients who need intensive treatment and will stay only a short time.

There’s also a difference in reimbursements. Long-term care, which involves a lower level of assistance, is reimbursed at a substantially lower rate than around-the-clock acute care. Even though Ida is in an acute-care hospital, the facility is reimbursed only at long-term rates.

According to a 2009 Healthcare Association report, the estimated uncompensated cost for long-term care patients staying in acute-care hospitals in Hawaii totaled approximately $72.5 million in 2008.

The problem for hospitals can be compounded when the patient is on government insurance.

"When someone’s on government insurance, it doesn’t pay the full cost of care," Clairmont said. "If you have too many in your hospital, you lose money every single day and eventually end up in trouble. That’s what a lot of community hospitals are facing today, especially as the population ages."

HMC has said its financial troubles were largely due to a high population of patients on government insurance.

HMC would not say how many of its remaining patients at Liliha are inappropriately placed in acute care, or how many are on Medicare, Medicaid or are without insurance. HMC has asked other care facilities in Hawaii to take its remaining patients and hopes to transfer them as soon as possible.

The surge in medical costs driven by new technology and Hawaii’s rapidly aging population has made it increasingly difficult for acute-care facilities to absorb losses related to long-term and government-insured patients.

Besides reimbursement issues, other facilities don’t have the capacity to treat long-term care patients, particularly if they have complex medical conditions.

"This is the big issue for the community; it’s a big, big problem," said Ida’s physician Eugene Wong. "There’s no other place outside in the community that will accept them … These long-term care facilities don’t get reimbursed any more for taking care of these patients."

The situation is only going to get worse as Hawaii’s population ages and requires more services, said George Greene, CEO of the Healthcare Association of Hawaii.

"We’ve got the most rapidly aging population in the country. We’re going to need more long-term care beds. Cases are going to be more complex," Greene said.

"This (Ida’s situation) highlights the fact there are more complex cases out there. Given that we live on islands where you can’t create more space, this is one of the biggest challenges the state faces."

The Healthcare Association is working with the state to expand the number of beds at medical facilities to accommodate the increased patient load brought on by HMC’s closures, he said.

"So far they haven’t been able to place me because I have several medical problems and I have renal dialysis," said Ida, a former Kaneohe resident who had several strokes and heart surgery in the past decade. "I’m sad but what can I do? I’m worried about the outside, where they’re going to place me."

If there are no facilities to take these patients, there is a possibility HMC would need to search out of state, Greene said.

"I would rather die" than be transferred to the mainland, said Ida, whose case is particularly critical since there are no long-term care facilities that do the specialized dialysis he requires. "Most of my family that’s still alive is in Hawaii, and half of them are elderly already."