Hawaii's biggest health insurer is changing how it pays doctors, and that is bad news for small clinics and patients who already struggle to find a doctor.

• HMSA is going back to paying doctors per visit or procedure instead of a flat rate per patient, and clinics say it will gut their income.
• One Big Island practice, Hilo Family Medicine, is closing at the end of September, blaming the payment change.
• HMSA will also stop paying doctors for patients who haven't come in for 18 months, wiping out a large share of some clinics' patient lists.
• Governor Josh Green pushed the start date to January, but most doctors switched early because staying on the old terms was made too costly.
• Hawaii is already short 20% to 40% of the doctors it needs, so more closures would leave patients with nowhere to go.

Outlook: More clinics are likely to close or cut services in the coming months, and HMSA's proposed merger with Hawaii Pacific Health will draw extra scrutiny.