Rural primary care a challenge locally

  • Dr. Richard Warner stands in his office on Lower Street in Buckland. He has been serving West County’s quaint community for nearly three decades, despite the many challenges that come with working as a primary care physician in a rural region. Staff photo/Andy Castillo

  • Dr. Richard Warner’s office on Lower Street in Buckland. He has been serving western Franklin County's rural communities for nearly three decades, despite the many challenges that come with working as a primary care physician in a rural region. Staff photo/Andy Castillo

  • Alyssa Valbona, Director of Sexual and Reproductive Health at The Community Health Center of Franklin County. Staff Photo/PAUL FRANZ—Paul Franz

  • Joel Feinman, president of the Valley Medical Group, in his Greenfield office. Staff Photo/PAUL FRANZ

  • Valley Medical Group’s Greenfield Health Center on Conway Street in Greenfield. Staff Photo/PAUL FRANZ

  • Community Health Center of Franklin County is in the Greenfield Center for Wellness on Man Street in Greenfield. Staff Photo/PAUL FRANZ—Paul Franz

  • Dental Assistant Kathie Cairns and Dental Director Allison van der Velden with a dental patient at The Community Health Center of Franklin County. Staff Photo/PAUL FRANZ

  • Ed Sayer, CEO at the Community Health Center of Franklin County. Staff Photo/PAUL FRANZ

  • Alyssa Valbona, Director of Sexual and Reproductive Health at The Community Health Center of Franklin County. Staff Photo/PAUL FRANZ—Paul Franz

  • Ed Sayer, CEO at The Community Health Center of Franklin County. Staff Photo/PAUL FRANZ—Paul Franz

  • Dental Director Allison van der Velden at The Community Health Center of Franklin County. Staff Photo/PAUL FRANZ—Paul Franz

  • Dr. Richard Warner in his offices on Lower Street in Buckland Center. At right, an eye chart just outside one of the patient rooms (photo at right by Andy Castillo). Staff Photos/PAUL FRANZ

  • Richard S. Warner, M. D. in his offices on Lower Street in Buckland Center. Staff Photo/PAUL FRANZ—Paul Franz

  • The Family Medicine offices of Richard S. Warner, M. D. on Lower Street in Buckland Center. Staff Photo/PAUL FRANZ

  • Stefan Topolski M.D. in his Shelburne Falls office. Staff Photo/PAUL FRANZ—Paul Franz

  • Trailside Health in Shelburne Falls. Staff Photo/PAUL FRANZ

  • Pamela and Craig Shrimpton live in the rural town of Hawley. Staff Photo/PAUL FRANZ

  • Pamela and Craig Shrimpton, who moved to the rural town of Hawley from Boston 14 years ago, say they’ve been unable to secure a primary care physician. “It’s a complete medical wasteland out here. There’s just nothing here,” Craig Shrimpton said. Staff Photo/PAUL FRANZ

  • Dr. Richard Warner stands in his office on Lower Street in Buckland. He has been serving West County's quaint community for nearly three decades, despite the many challenges that come with working as a primary care physician in a rural region. Staff photo/Andy Castillo—

Staff Writer
Published: 9/3/2019 1:06:41 PM

When Pamela and Craig Shrimpton moved from Boston to Hawley 14 years ago, they left behind more than the city’s bustle and noise. They left behind their regular primary care physician and haven’t been able to find a new one since.

For many Franklin County residents, the Shrimptons’ situation is all too familiar. The region has had a shortage of family physicians for decades, designated as “medically underserved” by the federal Health Resources and Services Administration in 1984 and retaining the distinction ever since. It’s a designation shared by several hilltowns in western Hampshire county, including Chesterfield, Cummington, Huntington, Middlefield, Plainfield, Williamsburg and Worthington

“It’s a complete medical wasteland out here. There’s just nothing here,” Craig Shrimpton said.

Since moving into the area, Shrimpton says they haven’t been able to find a primary care doctor who has openings for new patients. There are only two physicians running practices in the western end of Franklin County and neither accepts new patients. Instead, Shrimpton says he receives care at Baystate Franklin Medical Center in Greenfield and his wife drives a few times each year to a private practice in Deerfield. Both have only seen nurse practitioners. If there was an alternative, Shrimpton says he “would leave in a second.”

Compared to the rest of the state, Franklin County has a low number of family physicians. Of the county’s 71,000 residents, roughly 55 are primary care doctors (one for every 1,280 persons), according to this year’s County Health Rankings report, equaling only 5 percent of the total number of private practices operating in Massachusetts, based on 2014 census data compiled by the Massachusetts Department of Public Health. Meanwhile, the state average is one primary care doctor for every 950 persons. Elsewhere in Western Massachusetts, Hampshire County’s rate is 730 persons for every doctor; in Berkshire County it’s 930 persons for every physician; and, notably, there’s one doctor for every 1,400 persons in Hampden County.

To account for the shortfall in Franklin County, group practices in Greenfield and Turners Falls recruit constantly, shorten appointment times and have nurse practitioners serve as doctors. Meanwhile, the few independent family physicians remaining in the county struggle to make ends meet.

A ‘hand-to-mouth’ endeavor

The reason for this shortage of doctors is multifaceted, according to Dr. Richard Warner, one of two primary care physicians remaining in the expansive, sparsely populated western Franklin County region. The other doctor, Stefan Topolski, works out of an independent office in Shelburne Falls that doubles as his home. A third doctor, Bob Miller, retired earlier this year and the former West County Physicians closed several years ago.

Perched on a winding road in Buckland, Warner has served his community for 27 years. At any given time, Warner says he balances a cohort of about 1,500 patients. The 69-year-old doctor is a household name throughout the town. His patients, he says, are akin to “extended family.”

“I’m now seeing the children of those (original) patients, and even a few grandchildren,” Warner said. “The best part is you get to meet hundreds and hundreds of really interesting people.”

Despite dozens of residents traipsing through its doors each week, Warner’s practice is contemporary and immaculate. And yet, sitting in an office tucked in the back of his practice, he admitted that running his clinic is often a “hand-to-mouth” endeavor.

“I’ve been siphoning money from my retirement account for the last 10 years to cover expenses here,” Warner said. “You don’t save money.”

Like Warner, keeping his practice afloat “remains a very difficult struggle” for Topolski, the other West County physician, who noted that he earns $50 an hour — “the real wage” of a primary care doctors. This roughly equates to an annual salary of $104,000. 

The average wage of primary care doctors in Massachusetts is $203,000 per year, which is less than that of specialists, according to Medscape, an information hub for physicians and health care professionals. To compare, an average specialist earns $291,000 per year in Massachusetts.

“We started, we grew and we’re still here by keeping our overhead (costs) as small as possible,” Topolski said. “Not assuming we can afford anything. Not purchasing anything we don’t absolutely need.”

According to Topolski, the problems that rural doctors face are twofold: First, while private health insurance makes up the difference for low public reimbursements (generally, Medicare and Medicaid reimbursements are 30 to 50 percent less than private insurance reimbursements, Warner said), insurance does not completely cover the average primary care patient’s visit to the doctor. Second, steadily rising administrative requirements eat up hours of time that could be spent earning money.

“The state and federal requirements for paperwork keep piling on,” Topolski said. “Every division or department of the state, or the county, or the town — to them, it doesn’t mean much because it doesn’t mean much to them — but it’s literally dying of a thousand paper cuts. That’s the experience of anyone in primary care.”

In coming years, there could be a time when western Franklin County doesn’t have any local physicians at all. As Warner and Topolski are the only two doctors remaining in that region, they receive a constant influx of appointment requests. Warner has not officially accepted new patients in 25 years (although he receives two such inquiries per day), while Topolski’s first available appointment is several months away (although Topolski accepts walk-in patients for 5-minute appointments).

Despite the need for a more robust rural health care system, Topolski predicts that it’s unlikely new doctors will set up shop in western Franklin County due to the low financial yield of an independent office compared to more lucrative jobs at medical centers in larger cities. These costs are especially prohibitive to newly graduated doctors, Topolski continued.

“Younger doctors have such huge debt-loads. There’s no way they can afford to practice here,” Topolski said.

Without an end to his staffing problems in sight, Topolski says he has taken other measures to manage the unrelenting demand on his time. For example, he limits patient visits to 20 minutes, down from 40 minutes as was originally set. He is constantly looking for new doctors, without much success. Over the years, Topolski says he has hired a few older clinicians who, seeking more freedom and a quieter workplace, don’t mind a smaller paycheck.

However, despite his best efforts, Topolski says it’s become increasingly difficult to manage his business.

“We keep adding hours and we keep running faster on a treadmill that we never wanted to get on,” Topolski said. “It’s hard. That’s the pressure. To fit everybody in means seeing them quicker, and we don’t want to see them quicker.”

Ultimately, it’s the patients who pay the price. Because appointments are faster than he would like, Topolski says the quality of his care sometimes suffers.

“You can’t provide the medical care that you want for a person and sit down and actually listen and take your time and do it in a quality way for what you’re paid,” he said.

Great needs,but few doctors

The paucity of primary care doctors in this region has had a profound impact on patients like Betsy and Jack Kovacs of Heath. Because her husband has Parkinson’s disease, Betsy Kovacs, who serves as chairwoman of Heath’s Board of Health, said they “particularly need to have access to (local) health care.”

So far, to no avail.

“We have tried so hard to get seen to be seen by a local general practitioner,” she said, noting, “By ‘local’ I mean between Greenfield and Heath.”

Last January, the couple did manage to secure a regular primary care doctor at Cooley Dickinson Hospital in Northampton through their cousin, who works there as a pediatric cardiologist. However, it’s at least a 30-minute drive, which has posed problems in the past. Once, when her husband needed to see a local doctor in a more timely manner, Kovacs said they couldn’t get an appointment at any primary care offices in Franklin County and instead had to go to Baystate Franklin Medical Center’s emergency room.

For the couple, who retired to Heath from New York City about seven years ago, the difference in health care access is stark. She conceded that the short physician supply is an expected trade-off of living in a small town.

“It’s one of the realities of living in a very sparsely populated area,” she said.

As Kovacs said, the shortage of local doctors is not unique. It’s an issue facing remote communities across the nation, with one in four people living in rural areas saying they could not get access to health care, according to a poll published by NPR in May. However, the problem is acute in Franklin County at least in part because of the region’s rapidly aging population. A recent Community Health Needs report from Baystate Franklin Medical Center found that the county’s average age is projected to rise exponentially in the coming decades. The proportion of those 65 and older is expected to increase from less than 20 percent now to 35 percent by 2035.

And it’s not just the patients who are aging. Doctors are getting older, too.

At Connecticut River Internists in Turners Falls, all four of the office’s doctors and co-owners are between 64 and 68 years old and plan to retire in December after more than 30 years in practice. The physicians — Joseph Viadero, Adam Blacksin, Wayne Gavryck and Laurence Klein — were unable to recruit replacements. Baystate Franklin Medical Center agreed to acquire the practice Jan. 1, preventing its closure.

“The worst scenario would have been that we retired and our patients were left on their own,” Viadero said.

But while larger medical facilities in Greenfield try to fill gaps in surrounding hilltowns and smaller communities, they face staffing issues of their own. Edward Sayer, chief executive officer of Community Health Center on Main Street, said it’s difficult to recruit enough physicians and nurses to meet the public health demand. The Greenfield practice has had several positions vacant for months, now. Similarly, Valley Medical Group President Joel Feinman said that practice is “constantly recruiting” new physicians to fill chronic vacancies. Lacking an adequate number of physicians to accommodate demand, Feinman said the practice has created “care teams” that include a “physician, a nurse practitioner, a physician’s assistant and a few medical assistants.”

He highlighted a number of factors that are driving Franklin County’s primary care doctor shortage: the region is aging; it’s little known to outsiders; and, in general, the field is in decline.

“Going to medical school is expensive, and primary care doesn’t pay well, compared to the specialties,” Feinman said. “And you have to know a lot of things.”

The workload of a primary care physician is greater than that carried by doctors of other specialties, according to Dr. Dean Singer, who was raised in Greenfield and is the most recent hire at the Community Health Center of Franklin County.

“That’s a huge (reason) why people aren’t going into primary care,” Singer said. “Primary care has, unfortunately, gained a reputation of being a bad field of medicine to go into. There is a huge burn-out in primary care. We have to see a ton of patients.”

In addition to working three days a week at the center, Singer says he works part-time at Baystate Franklin Medical Center and Northern Hope Recovery Center on Federal Street in Greenfield. On average, Singer says he sees between 15 to 20 patients a day from 8 a.m. to 5 p.m. and then spends a couple of hours completing paperwork at home. The needs are great and the doctors are few.

“I could walk into every primary care office in all of Franklin County, and they would all hire me on the spot,” Singer said, noting he moved back to Greenfield to serve his hometown community. “I could go get five jobs today if I wanted to.”

Baystate’s Chief Medical Officer Kinan Hreib said he, also, is always looking to hire new doctors. Originally from Boston, Hreib was head-hunted by Baystate Franklin and moved into the area about a year ago for the job. He said Baystate is making an effort to improve the hospital’s efficiency in a number of different ways, among them by conducting appointments online and in groups (for patients with similar ailments).

Additionally and to draw more doctors to the region, Hreib says Baystate plans to open a new a facility to train physicians in family medicine. The residential program, where five experienced doctors will train 12 new doctors, is projected to open in 2022. Although Springfield’s Baystate Medical Center runs a few similar residential training programs, this will be the Franklin County facility’s first.

It’s not just primary care that don’t have enough doctors. Other specialties are also facing shortages. Of all physicians in Franklin County, dentists are in the shortest supply, according to this year’s regional Community Health Needs Assessment. The six dentists and one oral surgeon at the Community Health Center are constantly busy, according to Dental Director Allison van der Velden. The next open appointment in Greenfield is December as of July (though the center’s Orange office has appointments available in four to six weeks). Increasing the strain, the health center is one of only a few regional offices that accept public health insurance.

“The already small population of providers is chiseled down even smaller,” van der Velden said. “What it means for us? We’re really busy.”

Legislative action

The regional state senators Jo Comerford, D-Northampton, and Adam Hinds, D-Pittsfield, say they are aware that western Massachusetts has a shortage of physicians. To address the issue, the senators filed bills early this year seeking to expand medical access in the region. Hinds’ bill, S.153, would speed up the process of issuing licenses to physicians. If passed, the bill would require that a license application be is sued or rejected within 90 days. If a decision is not made in that period, a temporary registration would be given to a doctor.

He said this bill would “address a bottleneck” of physician applications. The proposal, he added, is one way that legislators can help to alleviate the “well-known” chronic doctor shortage in western Massachusetts.

Comerford’s bill, S.1221, seeks to expand loan repayments for doctors practicing medicine in cities that serve rural areas, she said. For example, Cooley Dickinson Hospital is based in Northampton, yet many patients come from remote areas with limited coverage.

“Cooley Dickinson serves rural communities, yet is not classically rural,” Comerford said. “Centers like Franklin Medical, serving a traditional rural community but not located in one, would be able to use this loan repayment to incentivize people to come and work there. Hopefully, we’d be able to staff up to adequate levels.”

Comerford said the bill is a response to a complaint she caught wind of on the campaign trail.

“I heard over and over again about the shortage of providers in rural areas,” Comerford said.

Meanwhile, Franklin County’s rural communities will continue to be served by the benevolence of physicians like Warner, Singer and Topolski, who say they find intrinsic value in serving their communities.

“We’re sort of the first line of defense,” said Singer, who returned to Greenfield after medical school in order to work in his hometown.

Warner, who in addition to being a doctor serves on Buckland’s health and Memorial Hall boards, said he has remained in town because of a personal conviction in the important role that physicians play in communities. Growing up, Warner said he looked up to his family’s physician, who practiced in a small town in Pennsylvania.

“That never changed. I saw that as an ideal way of practicing medicine,” Warner said. “I still feel that way.”

And while the sacrifices are great, Topolski said his reward lies in working in the town he loves and in serving his fellow neighbors.

“To live and work in your home with people coming by and be part of a community — this is how every doctor practiced before World War II,” Topolski said.


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