Doctors have often told me that Rhode Island is not an easy place for them. It’s particularly hard, they say, to hire new colleagues to come practice here. It’s about money. Local physicians, they say, get some of the lowest reimbursement rates of doctors in any state.

I got to wondering what that’s like for a doctor of a big practice who must often recruit. Not long ago, I sat down with the head of such a group to talk about it.

He asked that I keep his identity confidential because it wouldn’t work for a boss to talk frankly about how he pays his people. I try to avoid anonymous sources, but it was worth it to get an intriguing glimpse into a problem that could affect the quality of care over time. I can’t specify what procedures he does, either, because that could give him away.

I’ll call him, simply, The Doctor.

He’s been a surgeon for decades and now runs a practice with more than a dozen other docs. We sat down after hours at his office.

I began by asking where he’d rank us nationally in fees paid for medical procedures.

“In many if not most areas,” he said, “it’s 49th or 50th in the country.”

The reasons are complicated, he said — one factor being restrictive laws.

What kind of laws?

He mentioned several typical procedures for which Medicare will pay a doctor around $300, almost below cost, he said. In some states, top doctors can charge an extra few hundred for patients happy to pay for their expertise. Here, as in Massachusetts, the law forbids that.

“In other businesses,” he said, “when you get seniority and experience, you raise your prices. I make the exact same fees as the doctor fresh out of residency. The only way I make more money than that doctor is by seeing more patients. I’m not allowed to charge more for procedures.”

If Massachusetts has the same restriction, why is it worse here?

He said the state’s small size is a factor. It means less competition among insurers — there are really only two big players here, Blue Cross and UnitedHealthcare. In addition, he said, the few dominant hospital groups have the power to control payment rates to doctors.

If it’s that bad, why stay?

Because, The Doctor said, he’s from here, with roots and family. That, he said, is how practices like his often woo new recruits, by finding young doctors who want to live in the area, and will compromise on what they can make.

He said his group usually recruits one new physician a year. It’s not easy hiring doctors already here because there are fewer per capita in Rhode Island, and most are so busy they’re not in the market for new opportunities.

So he looks outside the state. It’s hard to compete, he said.

He gave the real example of a 30-something cancer doctor who recently finished his training. His offer in Rhode Island was $125,000 with three weeks vacation and being on call every third night — being available for patient calls or going to the hospital. On the West Coast, The Doctor said, this same candidate was offered $250,000, eight weeks vacation and “call” every 10th night.

How could that West Coast practice afford that?

He mentioned a routine procedure he does that private insurance in Rhode Island pays $390 for. Insurers in some states pay as much as $1,400. He admitted that’s an extreme, but said it’s common for fees here to be at least 20 percent below most other states.

To get good people, he told me, he often has to pay more than the fee structure justifies. Typically, he said, new doctors are expected to bring in more revenue than they earn, the rest going to the practice. But since fees here are so low, that would mean some sought-after new surgeons would be offered under $100,000, well below market. To recruit them, said The Doctor, he and his senior colleagues have to boost that by 50 percent or more from their own potential income. It’s common, he said, to “subsidize” new doctors for a few years before they start to break even in receipts.

“The idea,” he said, “is you hire somebody and they make money for the boss. That’s how business works. Here, you hire somebody and give them your money instead.”

But patients, I said, still pay high insurance premiums. Where does all that money go if not to doctors?

Ten years ago, he said, 40 percent of all local health-care dollars were paid to physicians. Now, he said, it’s about 25 percent because hospitals in particular have demanded a higher cut. The money also goes for needs ranging from rehab to pharmaceuticals.

The Doctor said he understands some of what insurers are up against — like having to cut fees to afford the steady increase in procedures given aging baby boomers. But he shows a bit of resentment at stories of insurers with expensive buildings or high CEO salaries.

He said in the decades he’s practiced here, doctors have become more squeezed than ever.

“Every year,” he said, “our expenses go up, our fees go down. Our income reduces. It’s getting tighter. Doctors are retiring earlier.”

Recently, he said, he told his recruiting agency he needed to hire a new surgeon for his group. So far, given the offer range, the agency hasn’t found anyone willing to interview.

He expects it to be a difficult search.

mpatinkin@projo.com