The doctor is in... demand; Ranks of primary care physicians are dwindling.

Byline: Elizabeth Cooney

WORCESTER - Maybe the doctor won't see you now.

That's the fear health-care organizations in Central Massachusetts are facing as they grapple with a shortage of primary care physicians that shows no signs of abating, despite constant recruiting efforts and creative inducements to help new MDs embrace the kind of care Americans need. The shrinking numbers of doctors coming out of training who are choosing family medicine, internal medicine or pediatrics is a national phenomenon, drawing the attention of policy makers and medical schools from coast to coast. But the crunch is especially acute in Massachusetts, thanks to its 2006 law requiring near universal coverage for its citizens.

Newly insured patients are catching up on their care, seeking doctors who will meet their need for regular, coordinated services designed to prevent problems before they develop and manage them comprehensively if they do. Ideally, that relationship will keep them out of hospital emergency rooms, which have become primary-care providers of last resort. But ER visits haven't fallen as quickly as expected in the first year of the health care law, an Urban Institute study reported recently, a likely sign of bottlenecks at the appointment desk.

"If we were just faced with replacing losses, we would be all right, but all of us are under enormous pressure to grow because people signed up for health insurance and we can't keep pace with the turnover, let alone grow," said Dr. Matthew J. Collins, vice president of medical services at Family Health Center and involved in recruiting at the community health center.

The shortage afflicts not only community health centers, but also hospitals and group practices. St. Vincent Hospital is bucking the trend altogether, opening up five primary care offices in Worcester and surrounding towns since last fall. It's a departure for the downtown hospital that defies the competitive landscape.

"In health care now, you're seeing incredible utilization of emergency rooms for primary-care reasons," said John E. Smithhisler, president and CEO of St. Vincent. "A better utilization of resources is to have those patients seen in primary care physician offices."

After seeing primary-care practices in the region open and quickly reach a saturation point, he said, the hospital decided to return to a primary-care relationship it last had with multi-specialty group practice Fallon Clinic in 1995, before the hospital changed ownership. St. Vincent has been successful in its recruiting efforts, Mr. Smithhisler said, offering salaries that range from $140,000 to $200,000 a year, depending on experience and skill level.

That's more than community health centers can afford, Dr. Collins of Family Health said, but still less than the $400,000 specialties such as radiology can offer to doctors not far removed from training. For doctors dedicated to the primary care among traditionally underserved people, there is a medical school loan repayment plan to help attract and retain physicians and nurse practitioners. A program funded by state and private sources pays up to $25,000 a year for three years in loan repayments, taking a bite out of the average of $130,000 debt that burdens medical school graduates. In exchange, recipients promise to work in primary care at a community health center for at least two years.

One doctor at Family Health and a doctor and a nurse practitioner at Great Brook Valley Health Center are taking part in the program, which helps level the playing field.

"We need to pay our physicians and nurse practitioners a reasonable salary. It comes down to dollars and cents," said Toni McGuire, head of the GBV community health center. "Would we like to have more physicians? Sure. We could see more patients. The patients don't stop coming. There are plenty of patients for all of us."

A Massachusetts Medical Society survey found that 51 percent of internal medicine doctors were accepting new patients last year, down from 66 percent in 2005. North of Worcester, only seven of 44 family practice doctors are accepting new patients, according to Community Health Connections of Fitchburg.

At UMass Memorial Health Center, about half of its doctors are open for new patients, according to Dr. Julia D. Andrieni, vice chair of medicine (clinical services) and chief of general internal medicine at UMass Memorial Medical Center. The health system counts about 500 primary care doctors at UMass Memorial Medical Center's three Worcester campuses, its primary care network in Central Massachusetts, and at member hospitals Marlboro Hospital, Clinton Hospital, Wing Hospital, and HealthAlliance in Fitchburg and Leominster.

"I'm optimistic," she said. "I think in crisis there is opportunity. I am seeing that some residents and some medical students choosing primary care seem to be the type of person who connects with patients from beginning to end and enjoys that continuity of care over long periods of time."

Sometimes primary care recruiters compete with a relatively new rival: hospitals hiring hospitalists, or doctors who specialize in caring for patients in the hospital. Within that specialty there are now family medicine hospitalists, who enjoy more regular hours and higher pay than their counterparts on the outpatient side of practice.

At Family Health, doctors still go on rounds at the hospital to see patients during their stays, Dr. Collins said, even with hospitalists on staff at most hospitals.

"From the time we close at night and on weekends, Family Health doctors are on duty to take your call or to deliver your baby and admit you into the hospital," he said. "We think we do a better job."

Friction has developed between the head of Hubbard Regional Hospital in Webster over the departure this spring of three primary-care doctors from the Fallon Clinic office built in 1995 on the hospital's campus. Fallon Clinic has said two of the doctors have left for different personal reasons and the third has moved into geriatric practice within Fallon. The remaining family practice physician splits his time between the Webster and Auburn Fallon locations, another doctor has been hired to fill in on a temporary basis to help care for the 5,500 patients there, and a nurse practitioner has been hired while recruiting continues for permanent replacements.

"We are committed to continuing to provide care for patients in the community," Dr. Robin Richman, Fallon Clinic chief medical officer, said last week.

Hospitals depend on primary care doctors to refer patients who need more specialized care, as Hubbard chief executive and financial officer William R. Falkowski made clear last month when he said that a significant percent of revenue came from Fallon. At St. Vincent, which employs its new primary care doctors at offices in Worcester, Auburn, Northboro, Shrewsbury, and Sterling, the hope is that patients will come to the hospital, but that's not a requirement, CEO Mr. Smithhisler said.

One of the newly hired doctors, Dr. Walter Goula, was one of the first three hospitalists hired at Miriam Hospital in Providence, but left that role to get back to greater day-to-day involvement with outpatients. Since arriving in January at the new office overlooking Indian Lake on Shore Drive in Worcester, he has been seeing eight to 10 patients a day.

"I keep hearing from patients, `I haven't been able to find a doctor,'" he said. "People who may not have had access to health care are looking to establish relationships."

Opening new practices and repaying medical school loans can go only so far in easing the shortage, Central Massachusetts doctors say. Sweeping change in the way insurers, following the government's lead, pay for health care will be needed, experts say. The system now pays doctors who perform procedures far more than doctors who counsel patients on how to avoid or manage chronic illnesses such as diabetes or heart disease.

"It's a perverse system that rewards intensity of care and procedures over primary care. There's enough awareness of what has to change, to redistribute existing health-care dollars to encourage the right kind of health care by prioritizing primary care," Dr. Collins said.

"I think things will start to change when people realize there are no doctors for them."

ART: PHOTO; GRAPH

CUTLINE: (PHOTO) Dr. Walter Goula, a new primary care doctor at St. Vincent Hospital, is pictured in the hospital's new primary care offices on Shore Drive in Worcester. (GRAPH) First-year M.D. program enrollment per 100,000

PHOTOG: (PHOTO) T&G Staff/TOM RETTIG (GRAPH) T&G Staff