Spokane is falling behind other communities in its ability to attract and retain primary-care physicians, the main source of health care for most Americans, a recent study here says.

Meanwhile, a large majority of primary-care doctors here no longer are willing to take on new Medicare and Medicaid patients, due to low reimbursements, says the study, conducted by Eastern Washington University researchers on behalf of the Spokane County Medical Society.

The medical society hired EWU's Institute for Public Policy and Economic Analysis to help it answer certain questions, including whether Spokane has enough primary-care doctors, whether Medicare and Medicaid patients here have adequate access to such doctors, and how the community could recruit and keep more primary-care doctors.

Among its findings:

•Nearly three-quarters of primary-care offices here don't have enough doctors on staff.

•Spokane has fallen below the national median for primary-care doctors per 100,000 population, and is considerably below Seattle and Portland in that measure.

•The community is expected to need about 20 new primary-care doctors annually during the next decade, but currently is attracting less than half that number.

•Only 29 percent of primary-care doctors here say they can afford to take on new Medicare and Medicaid patients.

"There is no one replacing the docs that are leaving the community—through retirement, mostly," says Dr. Jeff O'Connor, a primary-care physician at Providence Family Medicine at the Northpointe Medical Center. "The average age of primary-care providers here is close to 50."

O'Connor, who has been a primary-care doctor since 1978, believes there are enough primary-care doctors here now, but says "there's no future to it."

"Primary-care work is not valued particularly," he says. "It is in word, but not in reimbursement. Medical school graduates are going where the money is."

He adds, "If I was in their shoes, I'd probably be looking at specialty care."

Janet Monaco, the medical society's CEO, says the prospect of making more money as a specialist is a strong motivator for medical students, who typically have large college debts to pay off once they graduate and enter practice.

"It's impossible to do when you make very little money," Monaco says.

She says that primary-care physicians make, at the low end, about $80,000 a year. O'Connor estimates that medical school costs at least $90,000.

For purposes of the study, primary-care physicians included doctors who practice family or general medicine, internal medicine, pediatrics, or obstetrics-gynecology.

Monaco says the medical society plans to use the study to educate the community about the shortage.

D. Patrick Jones, who led the study and is the EWU institute's executive director, says one of the findings in the study that stood out to him was the high number of part-time primary-care physicians here, especially in the large practices. Of the 348 physicians who responded to the researchers' survey, about 20 percent were part time.

"A consequence of a high part-time count is the added challenge of meeting demand, as measured by hours (worked), for primary-care physicians," Jones says. "In other words, if a specialty such as pediatrics attracts another 20 doctors to Spokane, but they want to work 60 percent of a full-time schedule, then the community has gained 12 (full-time equivalent) doctors, not 20."

Monaco says there are about 400 family-care physicians currently practicing in Spokane County, down about 50 from five years ago.

"We're seeing that improve slightly (now), but not to the tune of 20 per year," she says. "We have never had that many come into our community in a year. The most we've ever had in a year was maybe 10."

She says, "The worst part of the shortage is yet to come."

About 40 percent of doctors here are primary-care physicians, with the rest specialists, Monaco says.

O'Connor says the workload is going up for primary-care doctors.

An 11-hour workday for a doctor often includes four hours of paperwork, and that's with computerized medical records, he says.

"We're swimming upstream all day long," he says.

The problem with having a shortage of primary-care doctors is that it impedes access to health care for everyone, since they are the principal contact most people have for their overall health care, Monaco says. Not having a primary-care doctor leads to fragmented care, she adds.

"Nobody then has the total picture," Monaco says. "That's not good for your health."

A shortage of primary-care doctors also can have an economic cost, she says. The report suggests that if Spokane patients used a specialist as their general source of care for chronic conditions, the cost of care would increase by $58 million a year.

Jones and the other researchers were surprised by the University of Washington's low production of medical students relative to other states Washington's size. The UW School of Medicine is the largest supplier of Spokane primary-care physicians.

"Measured against similarly-sized states, such as Indiana, Massachusetts, or Minnesota, Washington produces (fewer) than half the number of physicians per year, our calculations showed," he says.

A low number of medical-school graduates in the state, coupled with the trend of students choosing specialties rather than primary care, worsens the problem, Monaco says.

The EWU researchers found compensation to be a prime contributor to the low number of new primary-care providers here.

"Combined with national trends, the regional compensation trends for Spokane primary-care physicians are troubling," the report says.

It says the income of primary-care physicians has declined or stagnated in inflation-adjusted terms relative to that of other medical disciplines. "Spokane family-practice physicians have earned the least and have experienced the smallest gains over the decade," it says.

Among the other questions the study was intended to answer was what the community could do to attract and retain primary-care doctors.

"In the study team's view, the strategy with the highest payoff is to try to increase reimbursement, specifically Medicare reimbursement, since it plays an anchor role in setting fees for all other payers," the report says. "Dartmouth University's Atlas of Health Care reveals that Medicare pays Spokane-area primary-care physicians much less than the national average per patient visit and even less than the Washington state average." The Dartmouth Atlas project brings together researchers from different fields to study how medical resources are distributed and used in the U.S.

In a finding the report calls "curious," practitioners and managers at 91 percent of offices and clinics here surveyed by researchers felt that the salaries being offered here are adequate. In a small sampling of primary-care doctors who have left the market, however, one of the major reasons they gave for leaving was inadequate compensation.

To keep or attract primary-care doctors, Spokane needs to work aggressively with state and national lawmakers to improve debt-forgiveness programs and tuition waivers for medical students who commit to practicing primary care in Washington, the report says.

Another strategy, Monaco says, is to continue efforts to establish a four-year medical school program in Spokane.

"They are looking at that now," she says. Since August 2008, UW's medical school has had first-year medical students studying here. Monaco and others envision having a full four-year program here, which she says could bring about 600 medical students here once it was mature.

Still, "Having a four-year medical school in Spokane through the UW School of Medicine would be very expensive," she says.

Leila Gray, a spokeswoman for the UW School of Medicine, says the reason why the medical school has a first-year program in Spokane is to encourage the students to practice in Eastern Washington eventually. She says the first-year students here get the same core education as those studying in Seattle. Third- and fourth-year medical students serve as residents at hospitals, such as Providence Sacred Heart Medical Center & Children's Hospital, she says.

Monaco says Washington state is ranked 48th nationally in the number of medical students educated per capita.

"We have got to make primary care more attractive to folks," she says. About 20 percent of Spokane's primary-care doctors are UW School of Medicine graduates, both Monaco and the researchers say.

One way to make primary care more attractive is to offer to pay for students' medical schooling, if they agree to practice as primary-care doctors for four to five years in Washington, Monaco says.

With the report in hand, the medical society plans to begin talking soon with civic groups and state legislators, she says.