A country doc in Carson City
July 18, 2006
At all hours of the day, Dr. Robert Fliegler is on call. Sick patients can interrupt his dinner or rouse him from bed. They come to his sparsely furnished Carson City office or he goes to their home to administer shots, check blood pressure or conduct allergy tests.
Despite its demands, this is the profession that Fliegler prefers. He left Carson Tahoe Regional Medical Center for the life of a country doctor, who isn’t really in the country.
“The focus is on patients,” Fliegler said. “And unfortunately a lot of times the focus has become about the paperwork and about satisfying insurance companies’ demands. The patient care gets lost in the process.”
With a population reaching 60,000 and quick access to the most state-of-the-art equipment in the medical world, the capital city still needs something more, Fliegler says. He’s the city’s first concierge-only doctor, board certified in internal medicine. He believes some people want the personal relationship with their physicians that used to characterize the way health care was administered before HMOs and insurance companies.
“I feel like I am the old country doctor who used to be friendly with patients and not worried about forms and what’s covered by insurance,” he said.
This one country doc in Carson City is part of a growing nationwide movement that advocates for a revisited style of medical care. State medical officials say the practice is a way of getting refocused on patients in an age when the insurance company dictates many aspects of care.
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They say it’s one way to alleviate the costs associated with insurance claims, but it poses them as well if doctors can’t fill up their patient list.
For some people, meaning those with the money to pay the retainer fee, it can work, said Dr. Thomas Hunt, chairman of the Family and Community Medicine Department at the University of Nevada School of Medicine in Las Vegas. He doesn’t see this model overtaking the current system.
“It’s like upgrading,” Hunt said. “Instead of having a regular hotel room you get an upgrade to a suite.”
Hunt has some experience. He had a concierge doctor practice in Las Vegas resorts that catered to tourists.
“It’s hard to find enough people to pay the retainer to keep the practice going,” he said. “So what some physicians will do is have a smaller subset that are concierge.”
The concierge medical model works for Teena Fearheiley, of Carson City.
“It is nice to go to a doctor who has time to talk to me and returns phone calls,” she said. “And he can go to your home if needed. I think that’s a god send.”
Larry Matheis, Nevada State medical association executive director, calls it a phenomenon that reinvents a medical model popular in the 1950s. It has a new name, or several: VIP medicine, boutique, custom care, concierge and retainer.
This way of practicing medicine evolved as a market reaction to problems created by the way insurance companies reimburse doctors, Matheis said.
“In frustration physicians are looking at other models where they can have direct contract with a patient,” Matheis said. “And if they have the right size (practice) and can provide the services needed, then they can offer a variety of services that 30 or 40 years ago we expected from our family doctor.”
Sandra Davis, 60, chose the Carson City concierge practice because “that’s what I grew up with.” Her father, O.W. White, was a doctor in Carson City from the early 1940s to 1990s. He did a lot of home-based care.
“When I’m sick I want the doctor to pretend like I’m the only one that matters to him,” she said. “I think that’s natural for a lot of people.”
Davis had an abscessed tooth recently and was referred on to a dentist for a root canal. Because she’s allergic to Novocain and Xylocaine, Fliegler had to give her an allergy test. She said the $100 monthly retainer would add up to the same costs of going to another office and getting the lab results. But this way she gets a doctor for the entire month.
The personal-care practice is growing in Nevada, said Dr. S. William Pierce, president of the Nevada Academy of Family Practice. His Henderson office is traditional and is starting “custom care.”
“We’ve been looking at what’s wrong with the system and the biggest factor is insurance companies,” he said. “They are dictating what should be done, and they are charging patients more. And they are reimbursing the doctors less.”
Should insurance companies carry all that blame? No, says Troy Smith, vice president of Hometown Health, which covers more than 100,000 clients in the region.
He quoted a study that found three primary drivers for health-care cost increases: general inflation, increases in price above inflation and the effects related to utilization, such as consumer demand for new medical treatments and more intensive diagnostic testing.
“Certainly we would like to see an increase in access for all patients with care,” Smith said about concierge practice. “I understand there are a number of ways of increasing that access and this is one of them.”
Matheis said the new model can work financially because it removes the highest overhead cost to doctors: processing insurance.
To further his goal of personalized care, Fliegler is limiting his practice to 400 patients. In his second month of operation, VIP Medical Access has 12 patients enlisted.
“As a hospitalist I found myself at the beck and call of the ER, and this was not always with patients,” he said. “This morning I spent two-and-a-half hours with a patient. I would never have been able to do that before.”
The average physician is aware of the time crunch. If the average patient visit is 15 minutes, six of those minutes are spent on paperwork leaving nine for face time. Insurance companies, which includes Medicare and Medicaid, reimburse for some of those minutes, which encourages doctors to have more patients so that they can keep up with business costs, Fliegler said.
He desires to be nearly free from paperwork, so Fliegler is not accepting Medicare or Medicaid. He collects a monthly retainer – it starts at $100. Fifteen percent of his patients will be treated for free.
“So much money is spent on acquiring the reimbursement from Medicare/Medicaid and insurances,” he said. “By taking out that burden you save cash.”
The business side is handled mostly in cash. The medical side is small and mobile. Fliegler said his goal is to keep patients out of the costlier medical system with its added fees.
Any medical expenses outside of their concierge doctor’s office would cost them extra, said consultant Bob Conner.
“Generally those in the higher-end salary tax brackets are falling into seeking the ’boutique’ services, just because of the higher costs,” said Conner, who owns RSK Consulting. “People like those in the Incline tax bracket. I don’t know if there are enough people down here that are in that income bracket.”
If patients have a catastrophe, they go to the local hospital. An annual retainer for the doctor, lab fees and emergency medical care can add up quickly.
Matheis, the medical association executive director, said he believes it’s a more easily operable model in Carson City because of its smaller size. Physicians know one another and can easily make referrals.
To hear Fliegler speak, most people could afford the VIP treatment.
“A majority of patients signing up are middle income,” he said. “Or people who are self-employed or busy people who don’t have time.
Some of his patients are using a high-deductible catastrophic insurance plan and a health savings account, which is an untaxed savings account for medical expenses that rolls over year to year.
The medical community has some concerns, such as, whether concierge will increase pressure in the emergency department. It can also mean that people with a lot of medical problems may then be seeking catastrophic insurance coverage and that could drive costs up for everyone, Matheis said.
Despite the business risk, Fliegler is confident – so much so that he’s renovating an 1890s building on North Curry Street for his future offices. Renovated and updated for medical care, he’s expecting it to cost $150,000.
“People may say $100 (a month) is elitist but it’s not,” he said. “I’m doing it much cheaper than anyone else is doing it. In the end run, people are saving money.”
Different medical models and hybrids are being tested, Matheis said. Some will fail; some will succeed. They are all fueled by one principal problem.
“It’s a mix of frustrations with the system as it is,” he said. “As the right people connect, and the right services work, it very well might become a much more popular way of getting medical care.”
• Contact reporter Becky Bosshart at email@example.com or 881-1212.