TEDxMileHigh
P.J. Parmar: How doctors can help low-income patients (and still make a profit)
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Modern American health care is defined by its high costs, high overhead and inaccessibility -- especially for low-income patients. What if we could redesign the system to serve the poor and still have doctors make money? In an eye-opening (and surprisingly funny) talk, physician P.J. Parmar shares the story of the clinic he founded in Colorado, where he serves only resettled refugees who mostly use Medicaid, and makes the business case for a fresh take on medical service.
P.J. Parmar - Physician
Physician P.J. Parmar founded Ardas Family Medicine, a private practice that serves resettled refugees, and Mango House, a home for refugees with activities and services that include dental care, food and clothing banks, churches, scout troops and afterschool programs. Full bio
Physician P.J. Parmar founded Ardas Family Medicine, a private practice that serves resettled refugees, and Mango House, a home for refugees with activities and services that include dental care, food and clothing banks, churches, scout troops and afterschool programs. Full bio
Double-click the English transcript below to play the video.
00:13
Colfax Avenue, here in Denver, Colorado,
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was once called the longest,
wickedest street in America.
wickedest street in America.
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My office is there in the same place --
it's a medical desert.
it's a medical desert.
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There are government clinics
and hospitals nearby,
and hospitals nearby,
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but they're not enough to handle
the poor who live in the area.
the poor who live in the area.
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By poor, I mean those who are on Medicaid.
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Not just for the homeless;
20 percent of this country is on Medicaid.
20 percent of this country is on Medicaid.
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If your neighbors have a family of four
and make less than $33,000 a year,
and make less than $33,000 a year,
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then they can get Medicaid.
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But they can't find a doctor to see them.
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A study by Merritt Hawkins
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found that only 20 percent
of the family doctors in Denver
of the family doctors in Denver
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take any Medicaid patients.
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And of those 20 percent, some have caps,
like five Medicaid patients a month.
like five Medicaid patients a month.
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Others make Medicaid patients
wait months to be seen,
wait months to be seen,
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but will see you today,
if you have Blue Cross.
if you have Blue Cross.
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This form of classist
discrimination is legal
discrimination is legal
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and is not just a problem in Denver.
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Almost half the family
doctors in the country
doctors in the country
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refuse to see Medicaid patients.
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Why?
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Well, because Medicaid pays less
than private insurance
than private insurance
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and because Medicaid patients
are seen as more challenging.
are seen as more challenging.
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Some show up late for appointments,
some don't speak English
some don't speak English
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and some have trouble
following instructions.
following instructions.
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I thought about this
while in medical school.
while in medical school.
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If I could design a practice
that caters to low-income folks
that caters to low-income folks
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instead of avoiding them,
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then I would have guaranteed customers
and very little competition.
and very little competition.
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(Laughter)
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So after residency, I opened up shop,
doing underserved medicine.
doing underserved medicine.
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Not as a nonprofit,
but as a private practice.
but as a private practice.
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A small business
seeing only resettled refugees.
seeing only resettled refugees.
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That was six years ago,
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and since then, we've served
50,000 refugee medical visits.
50,000 refugee medical visits.
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(Applause)
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Ninety percent of our patients
have Medicaid,
have Medicaid,
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and most of the rest, we see for free.
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Most doctors say you can't
make money on Medicaid,
make money on Medicaid,
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but we're doing it just fine.
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How?
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Well, if this were real capitalism,
then I wouldn't tell you,
then I wouldn't tell you,
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because you'd become my competition.
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(Laughter)
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But I call this
"bleeding-heart" capitalism.
"bleeding-heart" capitalism.
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(Laughter)
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And we need more people doing this,
not less, so here's how.
not less, so here's how.
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We break down the walls
of our medical maze
of our medical maze
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by taking the challenges
of Medicaid patients,
of Medicaid patients,
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turning them into opportunities,
and pocketing the difference.
and pocketing the difference.
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The nuts and bolts
may seem simple, but they add up.
may seem simple, but they add up.
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For example, we have no appointments.
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We're walk-in only.
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Of course, that's how it works
at the emergency room,
at the emergency room,
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at urgent cares and at Taco Bell.
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(Laughter)
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But not usually
at family doctor's offices.
at family doctor's offices.
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Why do we do it?
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Because Nasra can't call
for an appointment.
for an appointment.
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She has a phone, but she
doesn't have phone minutes.
doesn't have phone minutes.
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She can't speak English,
and she can't navigate a phone tree.
and she can't navigate a phone tree.
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And she can't show up on time
for an appointment
for an appointment
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because she doesn't have a car,
she takes the bus,
she takes the bus,
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and she takes care of three kids
plus her disabled father.
plus her disabled father.
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So we have no appointments;
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she shows up when she wants,
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but usually waits less
than 15 minutes to be seen.
than 15 minutes to be seen.
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She then spends as much time
with us as she needs.
with us as she needs.
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Sometimes that's 40 minutes,
usually it's less than five.
usually it's less than five.
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She loves this flexibility.
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It's how she saw doctors in Somalia.
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And I love it, because I don't pay
staff to do scheduling,
staff to do scheduling,
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and we have a zero no-show rate
and a zero late-show rate.
and a zero late-show rate.
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(Laughter)
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(Applause)
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It makes business sense.
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Another difference is our office layout.
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Our exam rooms open
right to the waiting room,
right to the waiting room,
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our medical providers
room their own patients,
room their own patients,
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and our providers stay in one room
instead of alternating between rooms.
instead of alternating between rooms.
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Cutting steps cuts costs
and increases customer satisfaction.
and increases customer satisfaction.
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We also hand out free medicines,
right from our exam room:
right from our exam room:
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over-the-counter ones
and some prescription ones, too.
and some prescription ones, too.
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If Nasra's baby is sick,
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we put a bottle of children's Tylenol
or amoxicillin right in her hand.
or amoxicillin right in her hand.
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She can take that baby straight back home
instead of stopping at the pharmacy.
instead of stopping at the pharmacy.
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I don't know about you, but I get sick
just looking at all those choices.
just looking at all those choices.
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Nasra doesn't stand a chance in there.
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We also text patients.
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We're open evenings and weekends.
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We do home visits.
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We've jumped dead car batteries.
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(Laughter)
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With customer satisfaction so high,
we've never had to advertise,
we've never had to advertise,
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yet are growing at 25 percent a year.
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And we've become real good
at working with Medicaid,
at working with Medicaid,
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since it's pretty much the only
insurance company we deal with.
insurance company we deal with.
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Other doctor's offices
chase 10 insurance companies
chase 10 insurance companies
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just to make ends meet.
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That's just draining.
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A single-payer system is like monogamy:
it just works better.
it just works better.
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(Laughter)
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(Applause)
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Of course, Medicaid is funded
by tax payers like you,
by tax payers like you,
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so you might be wondering,
"How much does this cost the system?"
"How much does this cost the system?"
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Well, we're cheaper than the alternatives.
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Some of our patients
might go to the emergency room,
might go to the emergency room,
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which can cost thousands,
just for a simple cold.
just for a simple cold.
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Some may stay home
and let their problems get worse.
and let their problems get worse.
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But most would try to make an appointment
at a clinic that's part of the system
at a clinic that's part of the system
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called the Federally
Qualified Health Centers.
Qualified Health Centers.
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This is a nationwide network
of safety-net clinics
of safety-net clinics
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that receive twice as much
government funding per visit
government funding per visit
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than private doctors like me.
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Not only they get more money,
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but by law, there can only be
one in each area.
one in each area.
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That means they have a monopoly
on special funding for the poor.
on special funding for the poor.
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And like any monopoly,
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there's a tendency for cost to go up
and quality to go down.
and quality to go down.
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I'm not a government entity;
I'm not a nonprofit.
I'm not a nonprofit.
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I'm a private practice.
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I have a capitalist drive to innovate.
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I have to be fast and friendly.
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I have to be cost-effective
and culturally sensitive.
and culturally sensitive.
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I have to be tall, dark and handsome.
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(Laughter)
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(Applause)
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And if I'm not, I'm going out of business.
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I can innovate faster than a nonprofit,
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because I don't need a meeting
to move a stapler.
to move a stapler.
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(Applause)
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Really, none of our innovations
are new or unique --
are new or unique --
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we just put them together in a unique way
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to help low-income folks
while making money.
while making money.
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And then, instead of taking
that money home,
that money home,
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I put it back into the refugee community
as a business expense.
as a business expense.
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This is Mango House.
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My version of a medical home.
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In it, we have programs
to feed and clothe the poor,
to feed and clothe the poor,
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an after-school program, English classes,
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churches, dentist, legal help,
mental health and the scout groups.
mental health and the scout groups.
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These programs are run
by tenant organizations
by tenant organizations
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and amazing staff,
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but all receive some amount of funding
form profits from my clinic.
form profits from my clinic.
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Some call this social entrepreneurship.
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I call it social-service arbitrage.
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Exploiting inefficiencies in our
health care system to serve the poor.
health care system to serve the poor.
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We're serving 15,000 refugees a year
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at less cost than where else
they would be going.
they would be going.
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Of course, there's downsides
to doing this as a private business,
to doing this as a private business,
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rather than as a nonprofit
or a government entity.
or a government entity.
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There's taxes and legal exposures.
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There's changing Medicaid rates
and specialists who don't take Medicaid.
and specialists who don't take Medicaid.
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And there's bomb threats.
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Notice there's no apostrophes, it's like,
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"We were going to blow up
all you refugees!"
all you refugees!"
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(Laughter)
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"We were going to blow up
all you refugees,
all you refugees,
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but then we went
to your English class, instead."
to your English class, instead."
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(Laughter)
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(Applause)
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Now, you might be thinking,
"This guy's a bit different."
"This guy's a bit different."
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(Laughter)
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Uncommon.
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(Laughter)
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A communal narcissist?
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(Laughter)
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A unicorn, maybe,
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because if this was so easy,
then other doctors would be doing it.
then other doctors would be doing it.
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Well, based on Medicaid rates,
you can do this in most of the country.
you can do this in most of the country.
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You can be your own boss,
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help the poor and make
good money doing it.
good money doing it.
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Medical folks,
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you wrote on your school
application essays
application essays
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that you wanted to help
those less fortunate.
those less fortunate.
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But then you had your idealism
beaten out of you in training.
beaten out of you in training.
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Your creativity bred out of you.
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It doesn't have to be that way.
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You can choose underserved medicine
as a lifestyle specialty.
as a lifestyle specialty.
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Or you can be a specialist
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who cuts cost in order to see
low-income folks.
low-income folks.
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And for the rest of you,
who don't work in health care,
who don't work in health care,
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what did you write on your applications?
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Most of us wanted to save the world,
to make a difference.
to make a difference.
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Maybe you've been
successful in your career
successful in your career
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but are now looking for that meaning?
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How can you get there?
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I don't just mean giving
a few dollars or a few hours;
a few dollars or a few hours;
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I mean how can you use your expertise
to innovate new ways of serving others.
to innovate new ways of serving others.
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It might be easier than you think.
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The only way we're going to bridge
the underserved medicine gap
the underserved medicine gap
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is by seeing it as a business opportunity.
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The only way we're going to bridge
the inequality gap
the inequality gap
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is by recognizing our privileges
and using them to help others.
and using them to help others.
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(Applause)
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ABOUT THE SPEAKER
P.J. Parmar - PhysicianPhysician P.J. Parmar founded Ardas Family Medicine, a private practice that serves resettled refugees, and Mango House, a home for refugees with activities and services that include dental care, food and clothing banks, churches, scout troops and afterschool programs.
Why you should listen
P.J. Parmar is a family doctor who started and runs a primary care clinic, dental clinic, youth programs and other endeavors for resettled refugees in the Denver area. He focuses on process efficiencies in underserved primary care medicine and challenges the notion that private practices can't thrive while serving low-income patients. He has also been covered widely for his work founding a Boy Scout Troop for resettled refugees.
P.J. Parmar | Speaker | TED.com