My doctor has a radical plan to keep her small medical practice alive

At my last annual checkup, my doctor made a surprising announcement.

Dr. Stacey Nieder said reduced insurance reimbursements were cutting her income and she would have to lay off staff and downsize her office — to just herself.

Nieder hopes to use technology to set up a primary care practice without staff. Patients would make appointments and pay bills online. Arriving for an appointment, they would find a waiting room without a receptionist.

Nieder would weigh patients and take their vital signs herself rather than have a nurse do it. Her electronic medical record system would take care of charts and filing.

"I can't pay my staff and pay myself less money every year," Nieder said. "So I have to get rid of my staff and most of my lease."

Alaska's upside-down medical system pays the least to the doctors we rely upon the most, our family doctors. The small doctor office where you felt at home, developed a relationship with a provider and had plenty of time to talk is going away.

As I've reported before, primary care doctors have to run tight businesses and wrangle with insurance companies to get paid in a system that takes them away from the caring relationship with patients that originally attracted them to medicine.

Young people may not remember how it used to be.

My family began seeing Dr. Sheila Burke almost 30 years ago. She took care of us through four pregnancies and delivered three of our children (she was on vacation during one birth). At every visit she would ask for a complete update on each child. She remembered every detail.

Burke knew us as deeply as anyone in our lives. My checkups could last an hour as I shared concerns and she responded with stories from her own life. Sometimes she would bring medical textbooks into the exam room to really dig into an issue.

During the years we didn't have insurance, she would code these long visits as "brief" and load us up with bags full of free medicine samples.

Burke had a sign in the lobby warning that she held down rates by not carrying malpractice insurance. But she had a sizable staff, including a physician assistant, a nurse and several office workers. We knew them all, as they stayed many years.

When new laws required using electronic medical records, Burke retired rather than underwrite the cost of conversion and bring a laptop into the exam room.

It took me a while to find a new doctor I liked. I tried a big practice with lots of doctors and staff. It made me feel like a piece of meat going through a processing plant.

I found Nieder through a friend. She was like an updated version of Dr. Burke.

Nieder joined the Army to earn her medical degree and cared for patients at Fort Wainwright in Fairbanks. But she bridled at military interference in her medical decisions and left when she could, in 2001, moving to Anchorage.

Her independence and energy fit Alaska. She is a competitive mountain biker and coached kids in the sport. Her fitness goal this year is to run 500 miles and bike 5,000 miles while having moments of overwhelming joy at least two times a week.

"I got my two this weekend," she said. "Awesome."

I love biking and running too, and I immediately liked that Nieder concentrated in our first visit on the importance of a healthy lifestyle rather than finding medical problems to fix. And I liked that she treated me as a human being, met my eye, joked and connected like a new friend.

I don't know how much money she makes. She has two sons in college, at the University of Alaska Fairbanks and Oregon State University. She drives a Subaru Outback.

Besides seeing patients 20 hours a week in her own practice, she sees hospital patients under contract, consults at a hospital mental health unit, and works with two telemedicine networks delivering health care in rural Alaska.

She said her business manager received a notice from Premera Blue Cross Blue Shield of Alaska cutting reimbursement for some of her most common procedures. Most of her patients have Premera insurance, and Nieder calculated that she couldn't absorb the cut and still make enough money.

She had learned about one-person micropractices from Physician Moms Group, an online community of 65,000 female doctors around the country. She said she will follow through with the idea if she can find another doctor who also wants to do a micropractice so the two can cover for each other.

I contacted Premera to ask about the reduction in Nieder's compensation. A public affairs representative asked me not to write a column about it because negotiations with Nieder were not complete.

Premera Alaska president Jim Grazko wouldn't comment on Nieder's case but said the company is trying to put all primary care doctors on a standardized rate schedule. That could mean that some get reductions.

As I've written previously, specialist doctor groups and hospitals in Alaska face little competition and can demand inflated compensation when contracting with insurance companies.

But insurance companies can set primary care rates. If a doctor doesn't agree to contract rates, plenty of other doctors are available.

Premera controls 50 percent of Alaska's private market (which includes patients not covered by government plans for military, veterans, elders, Alaska Natives or the poor). Primary care doctors can't turn away half of customers, so Premera gets to call the shots.

Alaskans pay more for health care than anyone else on Earth, as the highest-cost state in the highest-cost nation. I'm not suggesting insurance companies should pay doctors more.

But if we can't afford doctors who sit down and listen, we're not spending our money well. It's another sign that competition doesn't work in this market and we need a new system.

The views expressed here are the writer's and are not necessarily endorsed by Alaska Dispatch News, which welcomes a broad range of viewpoints. To submit a piece for consideration, email commentary@alaskadispatch.com. Send submissions shorter than 200 words to letters@alaskadispatch.com or click here to submit via any web browser.