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Spokane, Washington  Est. May 19, 1883
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Hayden doctor, patients say flat-fee service is healthier alternative

Dr. Rich Samuel encourages a patient following an exam at his Hayden office Monday. His patients pay a flat monthly fee for his services. (Kathy Plonka)
Dr. Rich Samuel encourages a patient following an exam at his Hayden office Monday. His patients pay a flat monthly fee for his services. (Kathy Plonka) Buy this photo

He doesn’t ride a horse or carry a leather satchel with a stethoscope and forceps.

But patients describe Dr. Rich Samuel as a throwback to a

simpler time in medicine. He gets them in quickly for appointments, offers leisurely visits and even answers their calls at night and on weekends.

“We’re trying to go back to the old-time, country doctor approach,” said Samuel, a board-certified family physician in Hayden.

He also offers a far less complicated payment system. Patients can see Samuel all they need for a fixed monthly fee.

“We’re trying to change the game, so to speak, and you know, the game is well-entrenched,” the soft-spoken doctor said.

Samuel last fall switched his business to this direct care model, also known as a subscription or retainer-based practice. Patients pay based on their age for unlimited access, with no co-pays or extra costs.

He does not bill insurance and has opted out of Medicare and Medicaid reimbursement, freeing up more time to spend with patients. Samuel has capped his patient load at 400, a tenth of the number he juggled before October.

“We can’t have 4,000 patients and be able to maintain that slower pace and more intimate type of interaction,” he said.

Samuel gives patients his cellphone number and email address so they can reach him at night or on the weekend if they have an urgent care need. He figures he’s had about 10 after-hours calls in the four months he has operated under the new system.

“People in general are very respectful of my off time, but it’s also reassuring to a lot of people to know if there’s an emergency they can call and run it by me,” he said.

Ladina Merwin has gone to Samuel for 19 years and prefers the new subscription fee plan. She went in for four or five visits in the past month and said she’s glad she didn’t have to pay for each one or deal with insurance.

“It’s very cost-effective,” Merwin said. “It’s a huge relief, and it makes you say maybe I should go to the doctor versus staying home and getting sicker and not taking care of yourself.”

Her husband, who runs a towing company and repair shop, and their two children also see Samuel. The monthly fee for the family is $200.

“Now, if they’re injured, it’s like, ‘You’re going to the doctor.’ It’s not, ‘Let’s see how it plays out in a couple of days.’ ” she said. “It’s a huge comfort level for me, because I don’t stress about my kids’ health at all.”

The subscription approach, sometimes referred to as concierge medicine, originated in the mid-1990s as an alternative to conventional practices that bill through insurance companies, Medicaid and Medicare. The number of U.S. doctors using this model grew fivefold, to more than 750, between 2005 and 2009, according to the National Opinion Research Center at the University of Chicago.

“This is an experiment, which has been successful in a lot of other markets, but this is still a trial balloon here in northern Idaho, and in Spokane for that matter,” Samuel said.

It’s a rare approach in the Inland Northwest, but a few others are trying it. Spokane Internal Medicine offers an option for patients to pay a monthly fee of $69 for access to primary care, including lab work, chronic disease management and nutrition classes. The practice, with nine doctors and five nurse practitioners on staff, has offered its Direct Care service for three years.

Samuel said he was drawn to this approach to make his fees transparent and affordable and be able to give more attention to patient needs.

“Physicians tend to be overwhelmed with too many patients, not enough time with patients, government and insurance hassles,” he said.

That’s where Samuel found himself a decade ago, prompting him to leave the practice he started in Post Falls and open a new office in a commercial building along U.S. Highway 95.

“We eliminated the insurance middleman and we basically asked patients to pay at the time of service for their visit,” he explained. “And the fees that we charged were about a third to a half less because we didn’t have the overhead of billing insurance.”

That shift was meant to cater to a large number of uninsured patients in North Idaho, but the Affordable Care Act led Samuel to re-evaluate the approach last year. With low-income patients qualifying for subsidized insurance under the health care law, he morphed to the retainer-based model.

The monthly fee ranges from $30 for children to $125 for those 80 and older. It covers all services Samuel provides, including supplies and medications used during the visit.

Many of his patients opt to carry lower-cost catastrophic care insurance to cover the bulk of expensive hospitalizations, major surgeries and emergency room visits.

“They’re self-insured, they have a high-deductible insurance plan, and they use my services as their outpatient medical care,” Samuel said.

That’s what Mitchell and Machelle Wright decided to do. Ever-increasing insurance premiums led the couple to find major medical coverage for much less and sign up with Samuel last fall.

“The savings on the premiums alone will pay for our concierge service three or four times over,” said Mitchell Wright, who has been self-employed for 43 years.

“We wanted to get in with a practice that we would be assured of access and high-quality care at a reasonable rate,” he added. “And we wanted to start distancing ourselves from the insurance industry.

“It’s kind of like going back to having a family doctor like we used to have when I grew up in the 1950s.”

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