Conflict of interest alert: I am a physician and work for a health system with seven hospitals in it. Everything below is therefore self-serving, but not entirely so.

As state government considers cutting payments to Maine hospitals for the care of Medicaid patients by some physicians those hospitals employ, it would do well to remember that Maine hospitals (and a few federally qualified health centers) are all that prevents large parts of the state from becoming health care wastelands.

That is because, over the last decade, the safety net for physicians in Maine has become its hospitals. Without hospitals stepping in to employ them, many of these physicians would have left Maine or never have come here in the first place, and thousands of Mainers would be living in areas with no physicians to care for them.

More than 40 percent of Maine physicians are now employed by hospitals, according to the Maine Medical Association. In many communities, almost all of the physicians for miles around are employed by their local hospitals. In the northern half of the state in particular, without hospital employment there would be few family physicians, internists or psychiatrists, and fewer pediatricians than most kids can count using all of their fingers.

Among the physicians employed by Maine hospitals are some whose numbers are small but whose work is of statewide importance. They include the one or two urologists in the entire state who will see poor children, the trauma surgeons for every severely injured patient in the state, the only oral surgeon I know of providing on-call hospital services in the entire northern half of Maine, the only pediatric intensive care physicians north of Portland, and all of the gastroenterologists north of Waterville. Almost every brain surgeon in Maine is now employed by a hospital. Lose one or two of these physicians and you can lose all of the coverage of that specialty for more than 500,000 people.

Most of these physicians have sought hospital employment because they are tired of the growing burden of managing private practices, or because hospital employment has protected them from progressive cuts in their income brought on by dwindling reimbursement from Medicaid and private insurance companies. Current plans to increase Medicaid reimbursement to private physicians are too little, too late, and are unlikely to resuscitate the corpse of private medical practice in large parts of Maine.

State officials have defended the proposed cuts on the grounds that the federal government requires equity in state Medicaid payments between private and hospital-employed physicians. Cutting reimbursement to hospital-employed physicians to do this, however, seems like sinking another boat (hospital-employed medical practice) in order to treat it equally with the boat already resting on the bottom (private medical practice). Why not raise both boats instead, and pay fairly for medical care for Medicaid patients?

It’s tempting to think that without these hospital-employed physicians, patients could simply go elsewhere – to the next town, or Portland or Boston, perhaps. That is easier said than done, and for many reasons. Perhaps most importantly, some of the patients these hospital-employed physicians care for are critically ill and would not survive the trips to other physicians at other hospitals.

More commonly, many physicians in Portland and Boston are themselves too busy to take more patients, and some do not take Medicaid patients happily, if at all. Some physicians in Maine’s medical center communities are tired of accepting patients of any insurance type transferred in the middle of the night because another physician in the patient’s area has stopped taking hospital calls or left the area entirely. Many specialists are now essentially covering half the state of Maine when they are on call, something most of them never signed on to do.

It’s also tempting to tell well-paid physicians who want to protect their incomes to go whistle up their sigmoids, but Maine physicians are constantly being recruited to jobs in other states that provide better incomes and more time with family than is often possible in Maine. There are already hundreds of open physician jobs in Maine as a result, and little is being done other than hospital employment to prevent that number from rising rapidly.

Some will suggest that hospitals should make up the proposed reduction in state revenue by simply spending less money on new buildings and programs. That would work if hospitals did not need to replace equipment that is outdated, or renovate facilities that are too old to meet current standards of care and too small to keep up with the demand of growing patient volumes.

In addition, the state owes Maine hospitals more than $500 million in state and federal matching funds for care given in past years to Maine Medicaid patients. That means any capacity Maine hospitals once had to absorb further failure of the state to pay reasonably for physician services is probably long gone.

Finally, hospital-employed physicians also provide a disproportionate amount of the care given to Maine Medicaid patients because many private physicians can no longer afford to take care of large numbers of Medicaid patients. In some communities, hospital-employed primary care physicians are the only ones accepting new Medicaid patients in their practices. Cutting reimbursement to the physicians most willing to accept its patients is an exercise in foot-shooting.

Proposed Medicaid reimbursement cuts to hospitals for the services of physicians who are hospital-employed will disproportionately affect Maine’s sickest, poorest, and most rural patients. However, the cuts will also affect the rest of us, because Maine hospitals are now the thread by which many physicians are hanging on in Maine.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.