TEDxMileHigh
P.J. Parmar: How doctors can help low-income patients (and still make a profit)
PJ 帕爾馬: 醫生如何幫助低收入病人（且仍有利潤）？
Filmed:
Readability: 4
1,732,000 views
現代的美國醫療照護體系被視為是高價格、高經常性開支以及令人難以取得——尤其是對於那些低收入病人更是如此。假設我們可以重新設計一個能夠幫助窮人，而且醫生仍然能夠獲利的體制。在這個令人耳目一新（且出乎意料地搞笑）的演說中，PJ 帕爾馬醫生分享了他在科羅拉多州開立診所的故事。他的診所只為重新定居的難民服務，絕大部分都領有醫療補助，並成爲在醫療服務中新奇的商業實例。
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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科羅拉多州丹佛市的科法爾大道，
00:17
was once called the longest,
wickedest street in America.
wickedest street in America.
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在美國曾經被稱為是最長
且最邪惡的街道。
且最邪惡的街道。
00:22
My office is there in the same place --
it's a medical desert.
it's a medical desert.
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我的辦公室就設立在那裡；
這裡是醫療荒漠。
這裡是醫療荒漠。
00:26
There are government clinics
and hospitals nearby,
and hospitals nearby,
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儘管附近有衛生所及醫院，
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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但是不夠應付在這地區生活的窮人。
我指的窮人是接受醫療補助的人。
00:31
By poor, I mean those who are on Medicaid.
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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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它不光是指無家可歸者；
全國有 20％ 的人接受醫療補助。
全國有 20％ 的人接受醫療補助。
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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如果你鄰居是年收入
低於三萬三千元的四口家庭，
低於三萬三千元的四口家庭，
00:42
then they can get Medicaid.
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他們就可得到醫療補助。
00:44
But they can't find a doctor to see them.
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不過他們找不到肯為他們看診的醫生。
00:47
A study by Merritt Hawkins
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梅里特霍金斯公司的研究發現，
00:48
found that only 20 percent
of the family doctors in Denver
of the family doctors in Denver
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在丹佛，只有 20％ 的家庭醫生
00:51
take any Medicaid patients.
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肯為醫療補助的人看診。
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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在這 20％ 中部分的家庭醫生，
每個月最多只肯為五名這種病患看診。
每個月最多只肯為五名這種病患看診。
00:59
Others make Medicaid patients
wait months to be seen,
wait months to be seen,
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其他醫生甚至讓醫療補助的病患
等數月才會能去看診。
等數月才會能去看診。
01:02
but will see you today,
if you have Blue Cross.
if you have Blue Cross.
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但若你有藍十字保險，
他們今天就可替你看診。
他們今天就可替你看診。
01:06
This form of classist
discrimination is legal
discrimination is legal
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這種形式的階級歧視卻是合法的。
01:09
and is not just a problem in Denver.
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這問題不只發生在丹佛。
01:12
Almost half the family
doctors in the country
doctors in the country
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全國有近半數的家庭醫師
01:14
refuse to see Medicaid patients.
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拒絕為醫療補助的病人看診。
01:17
Why?
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為什麼呢？
01:18
Well, because Medicaid pays less
than private insurance
than private insurance
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因為政府醫療補助制度給付的金額
比私人保險給付的還要少，
比私人保險給付的還要少，
01:21
and because Medicaid patients
are seen as more challenging.
are seen as more challenging.
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而且他們認為為那些醫療補助的人
看病是項艱鉅的事。
看病是項艱鉅的事。
01:26
Some show up late for appointments,
some don't speak English
some don't speak English
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有人不準時赴約，有人不會講英語，
01:28
and some have trouble
following instructions.
following instructions.
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也有人難以遵守醫生的指示。
01:32
I thought about this
while in medical school.
while in medical school.
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我在醫學院時曾思考過這問題。
01:36
If I could design a practice
that caters to low-income folks
that caters to low-income folks
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如果我能夠設計一個診所
只為那些低收入的民眾服務，
只為那些低收入的民眾服務，
01:40
instead of avoiding them,
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而不是拒絕他們的話，
01:42
then I would have guaranteed customers
and very little competition.
and very little competition.
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我會有客源的保障，
而且幾乎沒有人會跟我競爭。
而且幾乎沒有人會跟我競爭。
01:47
(Laughter)
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（笑聲）
01:48
So after residency, I opened up shop,
doing underserved medicine.
doing underserved medicine.
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所以做了住院醫師後，我開了診所，
專門服務受政府醫療補助的人。
專門服務受政府醫療補助的人。
01:53
Not as a nonprofit,
but as a private practice.
but as a private practice.
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我的診所不是非營利，
而是私人開業診所。
而是私人開業診所。
01:56
A small business
seeing only resettled refugees.
seeing only resettled refugees.
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它是一個只為
已定居的難民看診的小診所。
已定居的難民看診的小診所。
02:02
That was six years ago,
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那是六年前的事，
02:03
and since then, we've served
50,000 refugee medical visits.
50,000 refugee medical visits.
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至今，我們已經做了
五萬次的難民醫療看診。
五萬次的難民醫療看診。
02:06
(Applause)
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（掌聲）
02:14
Ninety percent of our patients
have Medicaid,
have Medicaid,
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我們九成的病人有醫療補助，
02:17
and most of the rest, we see for free.
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剩下的一成，我們替他免費看診。
02:19
Most doctors say you can't
make money on Medicaid,
make money on Medicaid,
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大部分的醫生說
你在醫療補助病人的身上賺不到錢，
你在醫療補助病人的身上賺不到錢，
02:22
but we're doing it just fine.
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不過我們做到了。
02:24
How?
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怎麼辦到的？
02:25
Well, if this were real capitalism,
then I wouldn't tell you,
then I wouldn't tell you,
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如果我是純資本主義者，
我肯定不會告訴你們，
我肯定不會告訴你們，
02:28
because you'd become my competition.
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因為你們會成為我的競爭對手。
02:30
(Laughter)
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（笑聲）
02:31
But I call this
"bleeding-heart" capitalism.
"bleeding-heart" capitalism.
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我把這個稱為
「軟心腸的資本主義」。
「軟心腸的資本主義」。
02:34
(Laughter)
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（笑聲）
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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而且我們需要更多人參與而不是更少，
以下是我們如何辦到的。
以下是我們如何辦到的。
02:40
We break down the walls
of our medical maze
of our medical maze
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我們打破醫療迷宮的高牆，
02:43
by taking the challenges
of Medicaid patients,
of Medicaid patients,
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接受來自於醫療補助患者的挑戰，
02:45
turning them into opportunities,
and pocketing the difference.
and pocketing the difference.
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將它們轉變為機會
並且從其中獲得利潤。
並且從其中獲得利潤。
02:50
The nuts and bolts
may seem simple, but they add up.
may seem simple, but they add up.
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這些基本方法似乎很簡單，
不過它們確實能成大事。
不過它們確實能成大事。
02:53
For example, we have no appointments.
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舉例來說，我們沒有預約制度
02:56
We're walk-in only.
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我們只提供無預約服務。
02:58
Of course, that's how it works
at the emergency room,
at the emergency room,
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當然急診室、
03:01
at urgent cares and at Taco Bell.
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急症照護、塔可鐘速食連鎖
也是這樣運作的。
也是這樣運作的。
03:04
(Laughter)
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（笑聲）
03:05
But not usually
at family doctor's offices.
at family doctor's offices.
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但家庭診所通常不如此做。
03:08
Why do we do it?
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為甚麼我們要這麼做？
03:10
Because Nasra can't call
for an appointment.
for an appointment.
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因為納斯拉無法打電話預約門診。
03:13
She has a phone, but she
doesn't have phone minutes.
doesn't have phone minutes.
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她是有手機，但沒有打電話的額度。
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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她不會講英文
也不會使用電話的語音系統。
也不會使用電話的語音系統。
03:21
And she can't show up on time
for an appointment
for an appointment
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她無法準時在預約時間到診所，
因為她沒有車，她只能搭乘巴士。
03:23
because she doesn't have a car,
she takes the bus,
she takes the bus,
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03:26
and she takes care of three kids
plus her disabled father.
plus her disabled father.
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她要照顧三個孩子，
以及有殘疾的父親。
以及有殘疾的父親。
03:30
So we have no appointments;
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所以我們不提供預約服務。
03:31
she shows up when she wants,
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她想看診就直接來，
03:33
but usually waits less
than 15 minutes to be seen.
than 15 minutes to be seen.
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而且候診時間通常都少於十五分鐘。
03:37
She then spends as much time
with us as she needs.
with us as she needs.
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她可以依照她的需要和我們談。
03:41
Sometimes that's 40 minutes,
usually it's less than five.
usually it's less than five.
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有時候會花四十分鐘，
不過通常都少於五分鐘。
不過通常都少於五分鐘。
03:45
She loves this flexibility.
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她愛死這種彈性的看診。
03:47
It's how she saw doctors in Somalia.
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這也是她在索馬利亞的看診方式。
03:50
And I love it, because I don't pay
staff to do scheduling,
staff to do scheduling,
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而且我也愛極了，
因為我不需聘用員工來安排預約。
因為我不需聘用員工來安排預約。
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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我們有零缺席率以及零遲到率。
03:56
(Laughter)
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（笑聲）
03:59
(Applause)
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（掌聲）
04:04
It makes business sense.
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對生意來說很好。
04:06
Another difference is our office layout.
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另一個不同處是我們診所的格局，
04:09
Our exam rooms open
right to the waiting room,
right to the waiting room,
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我們的候診室直通檢查室，
04:11
our medical providers
room their own patients,
room their own patients,
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我們的醫生帶他們的病人到檢查室，
04:14
and our providers stay in one room
instead of alternating between rooms.
instead of alternating between rooms.
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而且我們的醫生有固定的檢查室
不必在不同房間來回。
不必在不同房間來回。
04:19
Cutting steps cuts costs
and increases customer satisfaction.
and increases customer satisfaction.
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減少來回走動降低成本，
並且提升病人的滿意度。
並且提升病人的滿意度。
04:24
We also hand out free medicines,
right from our exam room:
right from our exam room:
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我們也在檢查室提供免費的藥物：
04:28
over-the-counter ones
and some prescription ones, too.
and some prescription ones, too.
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不管是非處方藥
還是一些處方藥都有。
還是一些處方藥都有。
04:31
If Nasra's baby is sick,
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若是納斯拉的寶寶生病了，
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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我們直接遞給她一瓶兒童泰勒諾
（退燒／鎮痛劑）
（退燒／鎮痛劑）
或者是阿莫西林（抗生素）。
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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讓她可以直接帶小寶寶回家
而不是還要去藥局購買。
而不是還要去藥局購買。
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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不知道你會如何，不過我光是看到
這琳瑯滿目的選擇就頭痛。
這琳瑯滿目的選擇就頭痛。
04:47
Nasra doesn't stand a chance in there.
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納斯拉就更不用說了。
04:51
We also text patients.
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我們也寄簡訊給病人。
04:53
We're open evenings and weekends.
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我們在周末的夜晚也營業。
04:55
We do home visits.
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我們也做家庭探訪。
04:56
We've jumped dead car batteries.
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我們曾幫人啟動耗盡的汽車電池。
04:58
(Laughter)
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（笑聲）
05:00
With customer satisfaction so high,
we've never had to advertise,
we've never had to advertise,
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因為顧客滿意度極高
我們完全不用打廣告。
我們完全不用打廣告。
05:04
yet are growing at 25 percent a year.
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我們的生意每年成長 25％。
05:08
And we've become real good
at working with Medicaid,
at working with Medicaid,
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而且我們與醫療補助系統合作良好，
05:11
since it's pretty much the only
insurance company we deal with.
insurance company we deal with.
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因為它幾乎是
我們唯一合作的保險公司。
我們唯一合作的保險公司。
05:14
Other doctor's offices
chase 10 insurance companies
chase 10 insurance companies
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其他診所必須向
多間保險公司追討醫療給付，
多間保險公司追討醫療給付，
05:17
just to make ends meet.
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也只夠收支相抵。
05:19
That's just draining.
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那非常累人。
05:21
A single-payer system is like monogamy:
it just works better.
it just works better.
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單一保險公司就像是一夫一妻制，
它能更好地奏效。
它能更好地奏效。
05:25
(Laughter)
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（笑聲）
05:27
(Applause)
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（掌聲）
05:31
Of course, Medicaid is funded
by tax payers like you,
by tax payers like you,
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當然，醫療補助制度是由你們
這樣的納稅人所繳稅而來的，
這樣的納稅人所繳稅而來的，
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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所以你有可能會好奇：
「這個制度花了多少納稅錢？」
「這個制度花了多少納稅錢？」
05:38
Well, we're cheaper than the alternatives.
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答案是：比其他替代方案便宜多了。
05:41
Some of our patients
might go to the emergency room,
might go to the emergency room,
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我們有些病人可能去急診室，
05:43
which can cost thousands,
just for a simple cold.
just for a simple cold.
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可能要花幾千元
就只是為了一個小感冒。
就只是為了一個小感冒。
05:46
Some may stay home
and let their problems get worse.
and let their problems get worse.
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有些人可能就待在家裡，
病情變得更嚴重。
病情變得更嚴重。
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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但是大部分還是會選擇去預約
在這醫療補助體制下的門診。
在這醫療補助體制下的門診。
05:56
called the Federally
Qualified Health Centers.
Qualified Health Centers.
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也就是聯邦所核准的健康中心。
06:00
This is a nationwide network
of safety-net clinics
of safety-net clinics
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這是一個全國性的安全網的診所，
06:04
that receive twice as much
government funding per visit
government funding per visit
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每次看診就能從政府得到
比我們這樣的私人醫生，
比我們這樣的私人醫生，
06:08
than private doctors like me.
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兩倍的支付。
06:11
Not only they get more money,
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它們不只有更多錢，
06:13
but by law, there can only be
one in each area.
one in each area.
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根據法律，每個區域
只能有一個這種診所。
只能有一個這種診所。
06:16
That means they have a monopoly
on special funding for the poor.
on special funding for the poor.
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這代表它們可以壟斷
專給窮人的特設資金。
專給窮人的特設資金。
06:21
And like any monopoly,
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就像每個獨佔事業一樣，
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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都有價格上升但品質下降的趨勢。
06:27
I'm not a government entity;
I'm not a nonprofit.
I'm not a nonprofit.
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我不是政府單位，
我也不是非營利組織，
我也不是非營利組織，
06:31
I'm a private practice.
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我只是一個私人開業的醫生。
06:32
I have a capitalist drive to innovate.
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我被資本主義驅使去創新。
06:35
I have to be fast and friendly.
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我必須行動快速且友善。
06:39
I have to be cost-effective
and culturally sensitive.
and culturally sensitive.
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我必須要有成本效益
以及對文化敏感度高。
以及對文化敏感度高。
06:43
I have to be tall, dark and handsome.
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我必須要長的高、皮膚黑
且長的英俊挺拔。
且長的英俊挺拔。
06:46
(Laughter)
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（笑聲）
06:47
(Applause)
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（掌聲）
06:49
And if I'm not, I'm going out of business.
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如果我不是的話，我診所會關門。
06:52
I can innovate faster than a nonprofit,
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我的創新速度比非營利的更快，
06:54
because I don't need a meeting
to move a stapler.
to move a stapler.
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因為我不需要為了
移動一個釘書機去開會。
移動一個釘書機去開會。
06:57
(Applause)
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（掌聲）
07:03
Really, none of our innovations
are new or unique --
are new or unique --
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說實話，我們的創新
沒有一個是新的或獨特的，
沒有一個是新的或獨特的，
07:06
we just put them together in a unique way
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我們只是用一個獨特的方法去組合它，
07:08
to help low-income folks
while making money.
while making money.
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以幫助低收入的民眾
同時也賺到錢。
同時也賺到錢。
07:11
And then, instead of taking
that money home,
that money home,
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然後，我不是將錢占為己有，
07:13
I put it back into the refugee community
as a business expense.
as a business expense.
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而是將賺的錢當作事業支出
回饋給難民社區，
回饋給難民社區，
07:17
This is Mango House.
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這是芒果屋。
07:19
My version of a medical home.
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我的版本的醫療之家。
07:21
In it, we have programs
to feed and clothe the poor,
to feed and clothe the poor,
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在那裡我們有方案
提供食物以及衣服給窮人，
提供食物以及衣服給窮人，
07:24
an after-school program, English classes,
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以及課後輔導、英語課程、
07:27
churches, dentist, legal help,
mental health and the scout groups.
mental health and the scout groups.
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教會、牙醫診治、法律幫助、
精神健康問題協助以及童子軍團。
精神健康問題協助以及童子軍團。
07:33
These programs are run
by tenant organizations
by tenant organizations
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這些計畫由住戶組織執行
07:36
and amazing staff,
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還有那些很棒的員工。
07:38
but all receive some amount of funding
form profits from my clinic.
form profits from my clinic.
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這些人只有從我診所的
利潤中收取一些錢。
利潤中收取一些錢。
07:45
Some call this social entrepreneurship.
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有些人把這稱為社會化的創業精神。
07:49
I call it social-service arbitrage.
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我把它稱為有償的社會服務。
07:52
Exploiting inefficiencies in our
health care system to serve the poor.
health care system to serve the poor.
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利用我們健康照護系統的
低效率來幫助窮人。
低效率來幫助窮人。
07:57
We're serving 15,000 refugees a year
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我們每年服務一萬五千名難民，
08:00
at less cost than where else
they would be going.
they would be going.
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並且比起他們能去的其他診所，
我們收取更少的費用。
我們收取更少的費用。
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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比起非營利及政府單位，
08:08
rather than as a nonprofit
or a government entity.
or a government entity.
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我們這種私人事業有些缺點。
08:10
There's taxes and legal exposures.
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有稅要繳納並要遵循法律規章。
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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有變化不定的醫療補助比率
和不看醫療補助病人的專科醫生。
和不看醫療補助病人的專科醫生。
08:19
And there's bomb threats.
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還有炸彈威脅。
08:22
Notice there's no apostrophes, it's like,
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注意 WERE 這邊沒有撇號，
所以這句話意思應該像是
所以這句話意思應該像是
08:25
"We were going to blow up
all you refugees!"
all you refugees!"
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「我們本來要炸死你們這些難民！」
08:27
(Laughter)
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（笑聲）
08:33
"We were going to blow up
all you refugees,
all you refugees,
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「我們本來要炸死你們這些難民，
08:35
but then we went
to your English class, instead."
to your English class, instead."
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但後來我們改去上你們的英文課。」
08:37
(Laughter)
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（笑聲）
08:41
(Applause)
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（掌聲）
08:47
Now, you might be thinking,
"This guy's a bit different."
"This guy's a bit different."
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你現在可能會想
「這傢伙有點怪怪的。」
「這傢伙有點怪怪的。」
08:50
(Laughter)
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（笑聲）
08:51
Uncommon.
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不尋常。
08:52
(Laughter)
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（笑聲）
08:53
A communal narcissist?
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公共的自戀者？
08:55
(Laughter)
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（笑聲）
08:56
A unicorn, maybe,
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可能是獨角獸
（不在意世俗眼光的人）。
（不在意世俗眼光的人）。
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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因為如果要是這麼簡單的話
那其他醫生早就在做了。
那其他醫生早就在做了。
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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根據醫療補助比率，你也可以
在我們國家大部分地方這麼做。
在我們國家大部分地方這麼做。
09:04
You can be your own boss,
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你可以當你自己的老闆。
09:06
help the poor and make
good money doing it.
good money doing it.
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幫助窮人，且從中獲利。
09:09
Medical folks,
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那些從事醫學的人，
09:10
you wrote on your school
application essays
application essays
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你在你申請學校的論文上表示，
09:12
that you wanted to help
those less fortunate.
those less fortunate.
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你想要幫助那些沒有錢的人。
09:15
But then you had your idealism
beaten out of you in training.
beaten out of you in training.
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但是在你的培訓過程中
就打消了這理想的目標。
就打消了這理想的目標。
09:18
Your creativity bred out of you.
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你的創造力流失了。
09:21
It doesn't have to be that way.
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事情不需要變成這樣。
你可以選擇提供服務
給醫療不足的人做為你的生活方式。
給醫療不足的人做為你的生活方式。
09:24
You can choose underserved medicine
as a lifestyle specialty.
as a lifestyle specialty.
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09:29
Or you can be a specialist
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或者你能夠成為專科醫師，
09:30
who cuts cost in order to see
low-income folks.
low-income folks.
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降低費用為了幫低收入民眾看診。
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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在座其他不是從事醫療工作的人，
你們在你的求職信上寫了什麼？
09:37
what did you write on your applications?
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09:39
Most of us wanted to save the world,
to make a difference.
to make a difference.
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大多數的我們都想拯救世界，
並做出改變。
並做出改變。
09:43
Maybe you've been
successful in your career
successful in your career
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或許你事業有成，
09:45
but are now looking for that meaning?
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但目前正在尋找它的意義？
09:48
How can you get there?
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你要如何做呢？
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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我指的不只是投入一些錢或是時間，
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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而是你要如何利用你的專業知識
去創造一個新的方法來服務他人。
去創造一個新的方法來服務他人。
10:00
It might be easier than you think.
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這可能比你想像的還要簡單。
10:03
The only way we're going to bridge
the underserved medicine gap
the underserved medicine gap
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唯一可以減少
醫療服務不足的方法是
醫療服務不足的方法是
將這視為你生意的機會。
10:06
is by seeing it as a business opportunity.
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10:08
The only way we're going to bridge
the inequality gap
the inequality gap
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唯一可以減少不平等的方法是
10:11
is by recognizing our privileges
and using them to help others.
and using them to help others.
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認清我們的特權，並拿來幫助他人。
10:16
(Applause)
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（掌聲）
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