Dr. Dale Trombley, like a growing number of doctors, has found a way to cut his costs while providing what’s become an unfamiliar concept: a doctor who knows his patients.

“It’s nice to have a healthcare provider who knows you, who knows your issues, who watched you grow up,” said Trombley, who graduated from St. Louis University Medical School in 1974. “That’s what concierge patients are looking for. They want to see their doc.”

Trombley’s practice is referred to as a concierge medicine, fee for service, retainer medicine, or direct care. The practice has been growing in the U.S.; according to Concierge Medicine Today, the current number of concierge practitioners in the nation is about 6,000.

In practice, concierge medicine is not unlike a Netflix account or gym membership. The basic structure for all concierge practices involves paying a monthly or annual fee directly to the doctor in return for a range of healthcare options, anything outside of which must be paid by the patient or billed to insurance.

In Trombley’s family practice, Alaska Private Practice, a $4,500 per year prepaid fee covers 15 unlimited length office visits per year, along with whatever treatment Trombley can provide from his office. The office bills the patient directly, and the patient can send the bill to his insurance provider for reimbursement. Trombley has a cap of 375 patients.

The keys to the operation are limiting patients and avoiding direct contact with insurance providers, which is, in Trombley’s opinion, the biggest single waste of primary care physician resources in the modern medical environment.

“Insurance companies don’t want to pay,” said Trombley. “They want to pay for as little as possible, and they’re only now starting to pay for a doctor taking a call from their patient. They usually only reimburse if it’s face to face. The doctor is the last one to be paid. There was a switch from the patient being responsible to the insurance companies being responsible.”

That shift from patient- to insurance-centric payment, Trombley said, has caused a spiral of expensive office overhead followed by rising prices and bloated patient lists. In short, commercial insurance and federal medical entitlements have flooded primary care physicians with too many patients with not enough money, which only devalues healthcare while it inflates the price.

The operating cost from dealing with insurance companies is notoriously high. Forty percent of the average private practice physician’s overhead is directly tied to insurance claims management, whether hiring an office manager or some kind of extra staff to process claims.

To add to the problem, Medicare and Medicaid rarely pay out enough to doctors to cover expenses, Trombley said. According to an AMN Healthcare company Merritt Hawkins study, less than half of U.S. doctors accepted Medicaid patients in 2014.

“The government doesn’t pay out,” Trombley said. “Doctors lose money on those programs. They go broke.”

Both government regulations and insurance demands for larger returns create a conveyor belt of patients who only receive a minimal amount of face time with the actual doctor.

“If you look around, most doctors are part of an organization,” Trombley said. “And corporate is interested in the dollar, not the patient. They want you to push as many people through as possible. In a concierge situation, the time and the money is not a consideration. I don’t have the pressure of seeing 5,000 patients a year. I can address their needs. You get doctors who have to see thousands of patients a year. That doesn’t work. It doesn’t leave room for quality care.’

Where traditional medicine requires office appointments and insurance pre-approvals, Trombley even answered his phone during an interview with the Journal, requesting information and recommending a course of action to an office assistant.

“My patients pay me to sleep with my cell phone next to my head,” said Trombley.

Critics of “wealth care” point to the fees, which can vary nationally from a $50 monthly charge to tens of thousands a year, as prohibitive.

Trombley, however, insists that the price justifies itself. More personalized attention with a familiar doctor, plus free on-demand consultation, removes the vast bulk of need for expensive medical care. Familiarity means he can diagnose over the phone problems that might otherwise send a panicked patient to the hospital for unnecessary help.

“What would you rather do?” asks Trombley. “Have a regular doctor or go to the emergency room for $3,000 twice a year?”

Further, Trombley’s fee stacks up evenly or even less than the deductibles provided by all but the highest levels of commercial and government insurance.

According to a HealthPocket study, the average deductible for the Obamacare Bronze-tier plan, the lowest-priced option, is $5,181 for individuals and $10,500 for families, with $1,000 per month premiums.

According to a 2014 study by the Kaiser Family Foundation, the lowest average price for a 40-year-old’s silver plan coverage in Alaska is $488 per month.

According to a 2011 report for the Alaska Health Care Commission written by the University of Alaska’s Institute of Social and Economic Research, rising healthcare costs in Alaska are hitting businesses and families. At $11,926 per employee, Alaska has the highest average annual cost for employee health benefits in the nation, twice what employers in some other states pay. Between 2003 and 2010 the share of health benefits paid by employees increased from 17 percent to 22 percent for family coverage.

There are effects on Alaska businesses and employees. Higher health costs mean fewer employers can offer health benefits. The percentage of Alaska employers offering benefits dropped from 35 percent to 30 percent between 2003 and 2010, and during the same period, health insurance premiums climbed 35 percent for families to an average annual premium cost of $14,230 in 2010.

For Trombley, the issue simply boils down to the attention he can pay to a few hundred personalized patients instead of the thousands from a revolving door.

“In medical school, they taught us, ‘Doctor, if you don’t care about your patient, nobody cares about your patient,’” he said. “And I really took that to heart.”

DJ Summers is a reporter for the Alaska Journal of Commerce.