TEDxMileHigh
P.J. Parmar: How doctors can help low-income patients (and still make a profit)
PJ Parmar: 医生如何帮助低收入病人（且仍能盈利）
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Readability: 4
1,732,000 views
现代美国医疗的收费极高、间接支出也高并且难以获得——尤其对低收入患者而言。假如我们能重新设计这个系统，让它为穷人服务，同时还能让医生赚钱会怎样？在一次令人大开眼界(也出人意料的有趣)的谈话中，内科医生PJ Parmar分享了他在科罗拉多州创建的诊所的故事。在那里，他只为主要使用医疗补助的新定居的难民提供服务。
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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科尔法克斯大道位于科罗拉多州丹佛市，
曾被称为美国“最长，最邪恶的街道”。
00:17
was once called the longest,
wickedest street in America.
wickedest street in America.
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00:22
My office is there in the same place --
it's a medical desert.
it's a medical desert.
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我的办公室就在那儿——
那片医疗资源极度匮乏的地区。
那片医疗资源极度匮乏的地区。
00:26
There are government clinics
and hospitals nearby,
and hospitals nearby,
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虽然附近有政府诊所和医院，
但根本不够医治这个地区的穷人。
00:28
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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我所说的穷人是指
那些接受医疗补助的人。
那些接受医疗补助的人。
00:31
By poor, I mean those who are on Medicaid.
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不仅指无家可归的人；
美国有20%的人都接受医疗补助。
美国有20%的人都接受医疗补助。
00:34
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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00:38
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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如果你邻居家有四口人，
年收入不到33,000美元，
年收入不到33,000美元，
那么他们就能获得医疗补助。
00:42
then they can get Medicaid.
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00:44
But they can't find a doctor to see them.
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然而他们却找不到医生治病。
00:47
A study by Merritt Hawkins
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梅里特霍金斯公司做的
00:48
found that only 20 percent
of the family doctors in Denver
of the family doctors in Denver
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一个研究发现，
丹佛只有20%的家庭医生
丹佛只有20%的家庭医生
接受使用医疗补助的病人。
00:51
take any Medicaid patients.
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00:53
And of those 20 percent, some have caps,
like five Medicaid patients a month.
like five Medicaid patients a month.
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在这20%的医生中，有的有数量限制，
比如一个月看5位医疗补助病人。
比如一个月看5位医疗补助病人。
00:59
Others make Medicaid patients
wait months to be seen,
wait months to be seen,
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有些医生则让使用医疗补助的
病人等上几个月，
病人等上几个月，
但如果你有蓝十字医疗险，
你今天就能接受治疗。
你今天就能接受治疗。
01:02
but will see you today,
if you have Blue Cross.
if you have Blue Cross.
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01:06
This form of classist
discrimination is legal
discrimination is legal
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这种阶级歧视是合法的，
并且不仅丹佛存在这个问题。
01:09
and is not just a problem in Denver.
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01:12
Almost half the family
doctors in the country
doctors in the country
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几乎一半的美国家庭医生
都拒绝接收使用医疗补助的病人。
01:14
refuse to see Medicaid patients.
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01:17
Why?
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为什么？
因为医疗补助支付的金额比私人保险低，
01:18
Well, because Medicaid pays less
than private insurance
than private insurance
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而且人们总觉得接收
使用医疗补助的病人更麻烦。
使用医疗补助的病人更麻烦。
01:21
and because Medicaid patients
are seen as more challenging.
are seen as more challenging.
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01:26
Some show up late for appointments,
some don't speak English
some don't speak English
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他们有些人会迟到，有些人不会说英语，
有些人在遵循医嘱上也存在困难。
01:28
and some have trouble
following instructions.
following instructions.
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01:32
I thought about this
while in medical school.
while in medical school.
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在医学院时我就想过这些问题。
01:36
If I could design a practice
that caters to low-income folks
that caters to low-income folks
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如果我能设计出一个适合低收入人群
而非拒绝他们的医疗模式
01:40
instead of avoiding them,
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那么我的客源就有保证，而且竞争很小。
01:42
then I would have guaranteed customers
and very little competition.
and very little competition.
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（笑声）
01:47
(Laughter)
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所以在住院医生实习结束后，我开了
一家服务低医疗服务水平人群的诊所。
一家服务低医疗服务水平人群的诊所。
01:48
So after residency, I opened up shop,
doing underserved medicine.
doing underserved medicine.
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不是非盈利组织，而是私人诊所。
01:53
Not as a nonprofit,
but as a private practice.
but as a private practice.
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01:56
A small business
seeing only resettled refugees.
seeing only resettled refugees.
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一个小生意，只为重新安置的难民看病。
02:02
That was six years ago,
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那是在6年前，
自那之后，我们已经为
5万难民提供了医疗服务。
5万难民提供了医疗服务。
02:03
and since then, we've served
50,000 refugee medical visits.
50,000 refugee medical visits.
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（鼓掌）
02:06
(Applause)
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02:14
Ninety percent of our patients
have Medicaid,
have Medicaid,
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我们的病人中90%有医疗补助，
对其他剩下的大部分人，
我们提供免费诊疗。
我们提供免费诊疗。
02:17
and most of the rest, we see for free.
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02:19
Most doctors say you can't
make money on Medicaid,
make money on Medicaid,
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很多医生说你无法
在使用医疗补助的病人身上赚钱，
在使用医疗补助的病人身上赚钱，
但我们的收入还不错。
02:22
but we're doing it just fine.
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如何做到的呢？
02:24
How?
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02:25
Well, if this were real capitalism,
then I wouldn't tell you,
then I wouldn't tell you,
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如果这是资本主义，我可不会告诉你，
因为你们会成为我的竞争对手。
02:28
because you'd become my competition.
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(笑声)
02:30
(Laughter)
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但我把这称为“软心肠”的资本主义。
02:31
But I call this
"bleeding-heart" capitalism.
"bleeding-heart" capitalism.
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（笑声）
02:34
(Laughter)
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我们需要更多的人参与进来，
我们是这么做的。
我们是这么做的。
02:35
And we need more people doing this,
not less, so here's how.
not less, so here's how.
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我们把服务使用医疗补助的病人的
02:40
We break down the walls
of our medical maze
of our medical maze
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挑战转化为机会，
02:43
by taking the challenges
of Medicaid patients,
of Medicaid patients,
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并从中赚取差价，来解开我们的医疗谜题。
02:45
turning them into opportunities,
and pocketing the difference.
and pocketing the difference.
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02:50
The nuts and bolts
may seem simple, but they add up.
may seem simple, but they add up.
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螺母和螺栓看起来很简单，
但它们加起来却能发挥巨大的作用。
但它们加起来却能发挥巨大的作用。
比如，我们无需预约。
02:53
For example, we have no appointments.
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02:56
We're walk-in only.
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我们采取即到即诊的模式。
02:58
Of course, that's how it works
at the emergency room,
at the emergency room,
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也就是说，急诊室和
塔可钟（墨西哥快餐品牌）
塔可钟（墨西哥快餐品牌）
采用了相同的模式。
03:01
at urgent cares and at Taco Bell.
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03:04
(Laughter)
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（笑声）
但这些在家庭医生的办公室并不常见。
03:05
But not usually
at family doctor's offices.
at family doctor's offices.
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03:08
Why do we do it?
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我们为什么要这样做？
03:10
Because Nasra can't call
for an appointment.
for an appointment.
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因为像纳斯拉这样的人没法预约。
她有电话，但她没钱付话费。
03:13
She has a phone, but she
doesn't have phone minutes.
doesn't have phone minutes.
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她不会说英语，也不会查询通讯录。
03:17
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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03:21
And she can't show up on time
for an appointment
for an appointment
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她无法在预约时间准时出现，
因为她没有私家车，她需要乘坐公车，
03:23
because she doesn't have a car,
she takes the bus,
she takes the bus,
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并且她需要照顾3个小孩
外加她残疾的父亲。
外加她残疾的父亲。
03:26
and she takes care of three kids
plus her disabled father.
plus her disabled father.
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03:30
So we have no appointments;
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所以我们不提供预约服务；
她想来的时候就来，
03:31
she shows up when she wants,
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通常等待不到15分钟就能就诊。
03:33
but usually waits less
than 15 minutes to be seen.
than 15 minutes to be seen.
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03:37
She then spends as much time
with us as she needs.
with us as she needs.
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我们会充分保证她的就诊时长。
03:41
Sometimes that's 40 minutes,
usually it's less than five.
usually it's less than five.
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有时候是40分钟，但通常不到5分钟。
03:45
She loves this flexibility.
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她喜欢这种弹性。
她在索马里就是这样看医生的。
03:47
It's how she saw doctors in Somalia.
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03:50
And I love it, because I don't pay
staff to do scheduling,
staff to do scheduling,
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这也让我很开心，因为我不需要
额外雇人负责预约事项，
额外雇人负责预约事项，
我们的爽约率和迟到率为零。
03:53
and we have a zero no-show rate
and a zero late-show rate.
and a zero late-show rate.
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（笑声）
03:56
(Laughter)
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03:59
(Applause)
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（鼓掌）
这很有商业价值。
04:04
It makes business sense.
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04:06
Another difference is our office layout.
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另一个不同是我们办公室的布局。
我们的检查室和候诊室相通，
04:09
Our exam rooms open
right to the waiting room,
right to the waiting room,
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每个医生都和他们自己的
病人独享一个房间，
病人独享一个房间，
04:11
our medical providers
room their own patients,
room their own patients,
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我们的服务人员集中在一个房间里，
而不需要在两个房间之间来回穿梭。
而不需要在两个房间之间来回穿梭。
04:14
and our providers stay in one room
instead of alternating between rooms.
instead of alternating between rooms.
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04:19
Cutting steps cuts costs
and increases customer satisfaction.
and increases customer satisfaction.
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削减流程降低了成本，提高了客户满意度。
04:24
We also hand out free medicines,
right from our exam room:
right from our exam room:
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我们还在诊室分发免费药品：
非处方药和一些处方药。
04:28
over-the-counter ones
and some prescription ones, too.
and some prescription ones, too.
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如果纳斯拉的孩子病了，
04:31
If Nasra's baby is sick,
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我们会直接给她一瓶
儿童泰诺或阿莫西林。
儿童泰诺或阿莫西林。
04:33
we put a bottle of children's Tylenol
or amoxicillin right in her hand.
or amoxicillin right in her hand.
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她可以直接带孩子回家，
而无需再去药店。
而无需再去药店。
04:37
She can take that baby straight back home
instead of stopping at the pharmacy.
instead of stopping at the pharmacy.
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04:43
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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我不知道你们怎么想，
但我一见到这一大堆药就头晕。
但我一见到这一大堆药就头晕。
04:47
Nasra doesn't stand a chance in there.
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纳斯拉根本没法在这里买药。
04:51
We also text patients.
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我们也给病人发短信。
04:53
We're open evenings and weekends.
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我们晚上和周末都营业。
我们做家访。
04:55
We do home visits.
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我们把汽车电池都跑到没电了。
04:56
We've jumped dead car batteries.
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（笑声）
04:58
(Laughter)
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有这么高的客户满意度，
我们根本不用打广告，
我们根本不用打广告，
05:00
With customer satisfaction so high,
we've never had to advertise,
we've never had to advertise,
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还能以每年25%的速度增长。
05:04
yet are growing at 25 percent a year.
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05:08
And we've become real good
at working with Medicaid,
at working with Medicaid,
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我们变得很熟悉Medicaid的业务，
因为它几乎是我们
唯一合作的保险公司。
唯一合作的保险公司。
05:11
since it's pretty much the only
insurance company we deal with.
insurance company we deal with.
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05:14
Other doctor's offices
chase 10 insurance companies
chase 10 insurance companies
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其他医生的诊所同时
与10家保险公司合作
与10家保险公司合作
以实现收支平衡，
05:17
just to make ends meet.
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但收效甚微。
05:19
That's just draining.
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05:21
A single-payer system is like monogamy:
it just works better.
it just works better.
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单一支付方制度就像一夫一妻制:
它就是效果更好。
它就是效果更好。
05:25
(Laughter)
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（笑声）
（鼓掌）
05:27
(Applause)
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当然，医疗补助计划由像
你们这样的纳税人资助，
你们这样的纳税人资助，
05:31
Of course, Medicaid is funded
by tax payers like you,
by tax payers like you,
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所以你们可能会好奇，
“这个系统要花多少钱？”
“这个系统要花多少钱？”
05:35
so you might be wondering,
"How much does this cost the system?"
"How much does this cost the system?"
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我们比主流方案便宜。
05:38
Well, we're cheaper than the alternatives.
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05:41
Some of our patients
might go to the emergency room,
might go to the emergency room,
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我们有些病人去急诊室，
仅仅一个简单的感冒，
就要花数千美元。
就要花数千美元。
05:43
which can cost thousands,
just for a simple cold.
just for a simple cold.
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05:46
Some may stay home
and let their problems get worse.
and let their problems get worse.
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有些人则呆在家中，坐等问题恶化。
05:50
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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但是大多数人会尝试在
属于联邦授权医疗中心的
属于联邦授权医疗中心的
一个诊所预约。
05:56
called the Federally
Qualified Health Centers.
Qualified Health Centers.
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06:00
This is a nationwide network
of safety-net clinics
of safety-net clinics
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这是一个覆盖全国的诊所安全网络，
每次看病得到的政府资助
06:04
that receive twice as much
government funding per visit
government funding per visit
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是像我这样的私人医生的两倍。
06:08
than private doctors like me.
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06:11
Not only they get more money,
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他们不仅收取更高的费用，
根据法律，每个地区只能有一个。
06:13
but by law, there can only be
one in each area.
one in each area.
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06:16
That means they have a monopoly
on special funding for the poor.
on special funding for the poor.
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这意味着他们垄断了为穷人
提供的特殊资金。
提供的特殊资金。
06:21
And like any monopoly,
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跟任何垄断一样，
总是成本会上升，质量会下降。
06:22
there's a tendency for cost to go up
and quality to go down.
and quality to go down.
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06:27
I'm not a government entity;
I'm not a nonprofit.
I'm not a nonprofit.
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我不是政府实体，我不是非盈利组织。
06:31
I'm a private practice.
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我是个私人诊所。
我有资本主义的创新动力。
06:32
I have a capitalist drive to innovate.
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06:35
I have to be fast and friendly.
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我必须高效和友好。
06:39
I have to be cost-effective
and culturally sensitive.
and culturally sensitive.
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我得有成本效益和文化敏感性。
06:43
I have to be tall, dark and handsome.
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我必须又高又黑又帅。
（笑声）
06:46
(Laughter)
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（鼓掌）
06:47
(Applause)
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如果不具备这些，我的生意就会垮掉。
06:49
And if I'm not, I'm going out of business.
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我比非盈利组织在创新方面更高效，
06:52
I can innovate faster than a nonprofit,
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06:54
because I don't need a meeting
to move a stapler.
to move a stapler.
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因为我不需要开个会
来决定是否拆除缝合器。
来决定是否拆除缝合器。
06:57
(Applause)
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（鼓掌）
我们的创新都不是新的或独创的——
07:03
Really, none of our innovations
are new or unique --
are new or unique --
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我们只是用一种独特的方法
把它们组合在一起，
把它们组合在一起，
07:06
we just put them together in a unique way
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在帮助低收入人群的同时还赚钱。
07:08
to help low-income folks
while making money.
while making money.
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然后，我会把这些钱投入难民社区
07:11
And then, instead of taking
that money home,
that money home,
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作为商业支出，而不是拿回家。
07:13
I put it back into the refugee community
as a business expense.
as a business expense.
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07:17
This is Mango House.
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这是芒果屋。
我创建的医疗之家。
07:19
My version of a medical home.
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07:21
In it, we have programs
to feed and clothe the poor,
to feed and clothe the poor,
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在那里，我们为穷人提供食物和衣服，
提供课外项目，英语课，
07:24
an after-school program, English classes,
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教堂，牙医，法律援助，
心理辅导和童子军等项目。
心理辅导和童子军等项目。
07:27
churches, dentist, legal help,
mental health and the scout groups.
mental health and the scout groups.
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07:33
These programs are run
by tenant organizations
by tenant organizations
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这些项目由承租组织
和出色的员工运作，
07:36
and amazing staff,
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但他们都从我的诊所获得了一些资金。
07:38
but all receive some amount of funding
form profits from my clinic.
form profits from my clinic.
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07:45
Some call this social entrepreneurship.
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有人称之为社会企业家精神。
07:49
I call it social-service arbitrage.
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我称之为社会服务套利。
07:52
Exploiting inefficiencies in our
health care system to serve the poor.
health care system to serve the poor.
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利用我们卫生保健系统的
低效率为穷人服务。
低效率为穷人服务。
07:57
We're serving 15,000 refugees a year
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我们每年服务15,000位难民，
且比其他地方花费更少。
08:00
at less cost than where else
they would be going.
they would be going.
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08:05
Of course, there's downsides
to doing this as a private business,
to doing this as a private business,
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当然，作为私人企业，
既非非盈利组织，也非政府实体，
既非非盈利组织，也非政府实体，
做这个也有不利的一面。
08:08
rather than as a nonprofit
or a government entity.
or a government entity.
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有税收和法律风险。
08:10
There's taxes and legal exposures.
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08:14
There's changing Medicaid rates
and specialists who don't take Medicaid.
and specialists who don't take Medicaid.
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有不断变化的医疗补助率和
不接受医疗补助病人的专家。
不接受医疗补助病人的专家。
08:19
And there's bomb threats.
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还有炸弹威胁。
08:22
Notice there's no apostrophes, it's like,
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请注意，这里少了个标点符号，
所以表达的意思就变成了，
所以表达的意思就变成了，
“我们本来要炸掉你们这些难民！”
08:25
"We were going to blow up
all you refugees!"
all you refugees!"
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08:27
(Laughter)
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（笑声）
“我们本来要炸掉你们这些难民，
08:33
"We were going to blow up
all you refugees,
all you refugees,
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但后来我们去上了你们的英语课。”
08:35
but then we went
to your English class, instead."
to your English class, instead."
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（笑声）
08:37
(Laughter)
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（鼓掌）
08:41
(Applause)
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08:47
Now, you might be thinking,
"This guy's a bit different."
"This guy's a bit different."
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现在，你可能在想，
“这家伙的确有一套。”
“这家伙的确有一套。”
（笑声）
08:50
(Laughter)
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罕见。
08:51
Uncommon.
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（笑声）
08:52
(Laughter)
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一个公共自恋者？
08:53
A communal narcissist?
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（笑声）
08:55
(Laughter)
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也许还是独角兽，
08:56
A unicorn, maybe,
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但如果这么简单的话，
其他医生也会这样做。
其他医生也会这样做。
08:57
because if this was so easy,
then other doctors would be doing it.
then other doctors would be doing it.
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09:01
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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根据医疗补助率，你可以在
全国大部分地区这样做。
全国大部分地区这样做。
你可以做自己的老板，
09:04
You can be your own boss,
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帮助穷人并赚大钱。
09:06
help the poor and make
good money doing it.
good money doing it.
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医学院的人
09:09
Medical folks,
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可能在申请学校时说过
09:10
you wrote on your school
application essays
application essays
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你想帮助那些不幸的人。
09:12
that you wanted to help
those less fortunate.
those less fortunate.
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但你的理想情怀在训练过程中丢掉了。
09:15
But then you had your idealism
beaten out of you in training.
beaten out of you in training.
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09:18
Your creativity bred out of you.
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你的创造力不复存在了。
09:21
It doesn't have to be that way.
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你们本可以做得更好。
09:24
You can choose underserved medicine
as a lifestyle specialty.
as a lifestyle specialty.
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你可以选择医疗服务不足的
领域作为毕生专业。
领域作为毕生专业。
09:29
Or you can be a specialist
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或者你可以选择成为
降低成本，为低收入人群看病的专家。
09:30
who cuts cost in order to see
low-income folks.
low-income folks.
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09:34
And for the rest of you,
who don't work in health care,
who don't work in health care,
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对不从事医疗保健行业的其他人来讲，
你的申请表是怎么写的？
09:37
what did you write on your applications?
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我们大部分人想要
拯救世界，改变现状。
拯救世界，改变现状。
09:39
Most of us wanted to save the world,
to make a difference.
to make a difference.
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09:43
Maybe you've been
successful in your career
successful in your career
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你们也许在你们的职业中已足够成功，
现在正在寻找生活的意义？
09:45
but are now looking for that meaning?
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09:48
How can you get there?
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你如何能够实现那个目标？
09:51
I don't just mean giving
a few dollars or a few hours;
a few dollars or a few hours;
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我指的不是捐献一些钱或几个小时；
我的意思是你如何使用你的专业技能，
以新的方式去服务他人？
以新的方式去服务他人？
09:54
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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这可能没你想的那么难。
10:00
It might be easier than you think.
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10:03
The only way we're going to bridge
the underserved medicine gap
the underserved medicine gap
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我们能够弥补医疗服务不足的唯一方法
是将其视为商业机会。
10:06
is by seeing it as a business opportunity.
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我们缩小不平等差距的唯一途径
10:08
The only way we're going to bridge
the inequality gap
the inequality gap
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是认识到我们的特权，
并利用这些特权帮助他人。
并利用这些特权帮助他人。
10:11
is by recognizing our privileges
and using them to help others.
and using them to help others.
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10:16
(Applause)
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（鼓掌）
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