HELENA - Physician Kurt Kubicka spent a dozen years as a family doctor in Helena and served as many as 3,000 patients, but decided late last year to leave his private practice.

"It was a very, very difficult decision," he said. "I went into (medicine) anticipating I would continue to do family practice, and it was discouraging that it was becoming less and less viable."

Kubicka, who left to become a staff physician at the Veterans Administration Medical Center at Fort Harrison, is not the only primary-care doctor in Helena who recently has left his practice.

Eight physicians - four internists and four family doctors - have done the same in the Capital City in the past seven months, leaving thousands of patients without a regular doctor. That's a 25 percent drop in Helena's primary-care physician workforce.

The exodus means far fewer doctors in Helena to perform primary care, which most medical experts agree is the bedrock of a health-care system that is affordable and keeps its citizens healthy, by managing disease and preventing more costly medical procedures.

While the drop here is dramatic for such a short time span, it's not a phenomenon unique to Helena. Similar waves of primary-care physician losses already have swept through Butte and Missoula, and many smaller Montana communities find it tough to recruit and retain these front-line doctors.

"There are still tons of patients (in Butte) with no physician," says Butte doctor Brett Kronenberger, who left her private practice three years ago to become a "hospitalist," seeing patients only when they're in the hospital. "It's a struggle to get (my) patients taken care of when they leave the hospital."

Kronenberger says Butte has lost a half-dozen primary-care physicians since 2006, or one-fourth of those practicing.

What's going on? Simply put, primary-care physicians in the private sector are getting squeezed, financially and professionally.

They face high costs to run a practice, long hours, hassles with insurance companies, high patient loads - and not enough payment to make it worthwhile.

The reimbursement system for physicians in America rewards specialists who perform multiple procedures, such as a surgeon, rather than the primary-care physician who spends most of his or her time visiting with patients, analyzing their health problems and advising them how to manage those problems.

And as primary-care physicians leave their practices, it's hard to replace them. Only a fraction of medical-school graduates are choosing family practice or internal medicine as their specialty.

"We're heading to a system where care will be delivered by less trained, less qualified providers," Kubicka says, such as physician assistants and nurse practitioners. "And more often, you're going to be pinballed around, from specialist to specialist."

Kubicka says Helena's primary-care physician workforce has declined nearly 30 percent the past 18 months, including the eight who have left the past half-year.

Half of those departing doctors were internists, who are general practitioners who specialize in seeing older patients.

Jay Larson, a Helena internist in private practice, says Helena is down to six internists, the fewest he's seen in his 20 years of practice here.

Losing eight primary-care physicians means the community has lost 300 to 400 hours a week of medical care, and that isn't easy to replace, Larson says.

"This is a critical hit," he says. "Without a primary-care physician, there will be a lot more emergency-room visits. These people will have issues that need to be dealt with, and these people have nowhere else to go."

Of these eight Helena physicians, one joined St. Peter's Hospital in town as a hospitalist, and five went to work for the VA Health System, in Helena, Lewistown and Spokane, Wash.

Scott Falley, an internist who had worked for a practice owned by St. Peter's, left that job in May and started last month as the only physician at the VA's clinic in Lewistown.

"The way they do things (at the VA) sounds more attractive than what internists are facing in private practice," Falley says.

The VA, which serves military veterans, pays physicians a salary and gives them a set number or "panel" of patients they're responsible for. The doctor sees those patients and tries to keep them healthy and out of the hospital, helping manage whatever chronic disease or problem they may have.

VA doctors also have paid vacations, holidays and benefits, like any federal employee.

"You serve those patients; you see them when they need to be seen," Falley says. "You're income doesn't depend on how many you see. If you see 20 patients a day or 12, you're paid the same way. You just need to do a good job in seeing your panel."

Kronenberger, the Butte physician, says more and more primary-care doctors are choosing to become employees, rather than running their own practice.

"You can't make enough money without being a business entrepreneur," she says, and many don't want to do that.

Kronenberger left her internist practice and joined a regional company that employs doctors as hospitalists, contracting with hospitals to provide that service. She sees patients at St. James Healthcare, Butte's only hospital.

At St. Peter's Hospital in Helena, which employs three dozen doctors, its top officials say they're concerned about the recent loss of primary-care doctors in town. But they're not convinced it's hurting access to primary care.

David Lechner, a physician who heads St. Peter's Medical Group, says the hospital is adding a new primary-care physician in September and opened an urgent-care clinic last year. Patients who need a doctor can phone the hospital's call center and get an appointment within a day or two, he says.

"There are doctors available (here) to see patients on a daily basis," he says. "Before I even got here, there were doctors toward the end of their practice that slowed down or went out to the VA. That's a fairly common thread. …

"We need to study this a little bit more on what the capacity needs are, before we go out and recruit a whole bunch of folks to replace them, one by one."

John Solheim, president and chief executive officer at St. Peter's, says the hospital's mission is to maintain primary care and health-care access in the community, and that he's "cautiously optimistic" that good access to primary care in Helena can continue.

"Our numbers that we've seen indicate that people are still able to get access to care, when they truly need it," he says. "Is it access to their individual physician? It may not be, all the time. But access to physician care has been and will be available."

Longtime physicians, however, say popping in to see any doctor isn't the same as seeing the physician who has known you for many years.

"You can see someone you've never seen before, and who may or may not have access to your medical records," says David Jordan, another veteran Helena internist. "That's not what patients want. They want a doctor. They want their doctor."

Kronenberger says the shortage of primary-care physicians won't ease any time soon, in Butte or many Montana communities, or much of the nation, for that matter.

"It's going to take a long time to recover," she says. "Until they ramp up and change the reimbursement system, you won't see many people (going into primary care). … I think we're going to continue to have a primary-care crisis in Montana."