Published by Michael L. Diamond in the Asbury Park Press.

Dr. Jason Nehmad needs help.

A primary care doctor, he sees four patients an hour. He takes 10 minutes for lunch. He is paying off more than $200,000 in student loans. And his colleagues are retiring in waves.

“It’s getting worse and worse,” said Nehmad, 35.

New Jersey is trying to combat a shortage of primary care doctors, starting new residency programs, building a new medical school and searching for options that can ease doctors’ workload.

It is scrambling as Obamacare prods consumers to see a primary care doctor each year and take preventive steps that will avoid costly illnesses down the road. The idea is a core tenet of the Affordable Care Act.

But putting it into practice hasn’t been easy. In Ocean County, for example, there are 2,140 residents for every primary care doctor, far worse than the statewide ratio of 1,170:1, according to the Robert Wood Johnson Foundation, a Plainsboro-based charitable organization that studies health care.

“Primary care doctors are really the first piece of prevention in terms of our health,” said Toni Lewis, a coach with the foundation who works with communities to improve population health. “It’s important to have access to primary care doctors so people can stay healthy.”

From business to medicine

Nehmad works for Hackensack Meridian Health and has his own practice in Jackson.

He didn’t always want to be a doctor. He grew up in Brooklyn and went to Yeshiva University in New York City, where he studied business and economics.

But he wanted to give back. So after his sophomore year, he went to Israel and worked as a paramedic. He liked the intensity and the idea of helping people. When he returned, he switched to pre-med.

Nehmad applied to U.S. medical schools, but didn’t get in, turning to the American University of Antigua College of Medicine, one of a handful of medical schools in the Caribbean whose students complete the same course work and pass the same medical boards as their American counterparts.

After four years of medical school, Nehmad did his three-year residency program at Jersey Shore University Medical Center in Neptune, settling on primary care instead of a specialty.

“I gravitated toward it,” he said. “There wasn’t a specific thing that attracted me enough to go into it. If you’re going to go into it, you’re going to do that for the next 35, 40 years of your life and just that. I liked a little bit of everything and not just one thing, so I thought primary was the best option.”

“Plus,” he said, “there was a huge demand in the area.”

Nehmad completed his residency in 2013, and his timing was perfect. Obamacare not only expanded insurance coverage, but also it envisioned primary care doctors as coaches who would manage their patients’ health over the long haul.

Insurance plans reflect that. They offer preventive care — screening for depression, tobacco use, obesity, diabetes and so on — without requiring a co-payment.

Supply and demand

But the supply of primary care doctors hasn’t kept up with the demand, particularly in more rural areas of the state.

Ocean Health Initiatives has seen the impact. The organization has five clinics in Ocean County, mainly giving Medicaid patients access to primary care. It treated 26,555 patients last year, a 10 percent increase from 2015.

And its future is shaky. Congress has yet to approve funding that is scheduled to run out at the end of the month.

“It’s difficult to hire primary care physicians,” said Warren Sherard, vice president of operations for Ocean Health Initiatives. “The H.R. department is pulling their hair out all the time to get doctors in the door.”

The shortage isn’t affecting everyone. Monmouth County has 890 primary care doctors for every resident, better than even the top-performing counties nationwide, according to the Robert Wood Johnson Foundation.

But it, too, might feel an upcoming pinch. Primary care doctors from the massive baby boom generation are nearing retirement.

New Jersey will need an additional 1,116 primary care physicians by 2030, a 17 percent increase from 2010, according to a report by the Robert Graham Center, a Washington, D.C., lobby group.

The reason might be as simple as money. In New Jersey, general practice doctors in 2016 made on average $183,410; surgeons made on average $286,710, or 56 percent more, according to the U.S. Bureau of Labor Statistics.

And Ciminelli, who is the director of the family medicine residency program at CentraState in Freehold Township, said less than half of her residents have stayed in New Jersey after they graduate.

“For many of them, it’s because they can make up to $100,000 more going to practice in other states,” she said. “They’re being offered bonuses, sign-on bonuses and opportunities for loan redemption. Those are big factors.”

Looking for doctors

Medical schools and hospital networks are trying to increase the supply of primary care doctors.

Nehmad’s medical school, the American University of Antigua College of Medicine, graduated 241 students in June. And it routinely attracts a higher number of students who want to go into primary care, said Neal Simon, the school’s president and co-founder.

Meanwhile, New Jersey’s two biggest hospital networks are aligning with medical schools in what they hope will be a boost to primary care.

Hackensack Meridian Health is planning to open a medical school at Seton Hall University in South Orange next year. And one of its hospitals, Ocean Medical Centerin Brick, is starting a residency program with a focus on primary care, said James Clarke, vice president of primary care at Hackensack Meridian.

“The real opening, I believe, is, here I am training in another state and I get comfortable for three years. And you say, ‘I should probably live here,'” Clarke said. “That’s what we’re trying to obtain: doing these kinds of commitments for residency throughout the system.”

RWJBarnabas Health and Rutgers University said this summer they would form a partnership to give medical school graduates more options to set up their practice in the Garden State.

Until now, “we haven’t had an … approach where the entire health system is aligned and working together,” said Vincente Gracias, a senior vice chancellor at Rutgers.

That might take years to pay off. For now, providers are trying to ease the burden on primary care doctors by opening urgent care centers and clinics in pharmacies; steering patients to physician assistants, nurse practitioners and social workers.

And they’re being creative. Ocean Health Initiatives opened wellness programs at Lakewood High School and Clifton Avenue Elementary School in Lakewood. The school nurse, who once treated students only when they got sick, now focuses on prevention with students and their families.

“Primary care is in the driver’s seat with all these models,” said Linda Schwimmer, president and chief executive officer for New Jersey Health Care Quality Institute, an advocacy group.

For Nehmad, the backup can’t come fast enough.

He scarcely has time to take a breath between seeing patients at Jersey Shore University Medical Center and his practice in Jackson, knowing he could book patients around the clock.

“You’re exhausted,” Nehmad said, before checking up on a patient at the hospital who was recovering from a stroke. “But, no, I wouldn’t do anything else.”