P.J. Parmar – TEDxMileHigh TRANSCRIPT
Colfax Avenue here in Denver, Colorado, was once called the longest, wickedest street in America. So there I was on Colfax Avenue, East Colfax at 2:00 a.m. with thirteen drunk teenage boys. I was scout master of an all refugee Boy Scout troop and had taken a few dozen boys camping. Most of them were asleep, but these thirteen had snuck beer into their tents and were drunk by midnight.
So we were taking them home one by one. As I walked the last boy to his apartment, I heard gunshots on the next block. As he turned on his kitchen light, I saw roaches scatter on the counter. And as his dad came out of the bedroom, I noticed four people were asleep on the living room floor. I showed dad a picture I had taken of the bottles we had found and gave him a look that loosely translated as, “I caught your son peeing on the campfire.” Dad had beer on his breath too.
I knew him because he was one of my patients. I knew the four on the floor because they were my patients. All of my scouts are my patients. That’s East Colfax, that’s where I’m a family doctor, and that night, I was practicing medicine. My office is there in the same place.
It’s a medical desert. There are government clinics and hospitals nearby, but they’re not enough to handle the poor who live in the area. By poor I mean those who are on Medicaid, free health insurance from the government. It’s not just for the homeless, 20% of this country is on Medicaid. If your neighbors have a family of four and make less than 33,000 a year, then they can get Medicaid, but they can’t find a doctor to see them.
A study by Merritt Hawkins found that only 20% of the family doctors in Denver take any Medicaid patients, and of those 20%, some have caps, like five Medicaid patients a month. Others make Medicaid patients wait months to be seen but will see you today if you have Blue Cross. This form of classist discrimination is legal and is not just a problem in Denver. Almost half the family doctors in the country refuse to see Medicaid patients.
Why? Because Medicaid pays less than private insurance, and because Medicaid patients are seen as more challenging. Some show up late for appointments, some don’t speak English, and some have trouble following instructions.
I thought about this while in medical school. If I could design a practice that caters to low-income folks instead of avoiding them, then I would have guaranteed customers and very little competition. After residency, I opened up shop doing underserved medicine, not as a non-profit but as a private practice, a small business seeing only resettled refugees. That was six years ago, and since then, we’ve served 50,000 refugee medical visits.
90% of our patients have Medicaid, and most of the rest, we see for free. Most doctors say you can’t make money on Medicaid, but we’re doing it just fine. How? If this were real capitalism, I wouldn’t tell you because you’d become my competition. But I call this bleeding-heart capitalism, and we need more people doing this, not less. So here’s how.
Break down the walls of our medical maze by taking the challenges of Medicaid patients, turning them into opportunities, and pocketing the difference. The nuts and bolts may seem simple, but they add up.
For example, we have no appointments. We’re walk-in only. Of course, that’s how it works at the emergency room, at urgent cares, and at Taco Bell – but not usually at family doctors’ offices.
Why do we do it? Because Nostra can’t call for an appointment. She has a phone, but she doesn’t have phone minutes. She can’t speak English, and she can’t navigate a phone tree. She can’t show up on time for an appointment because she doesn’t have a car, she takes the bus, and she takes care of three kids plus her disabled father. So we have no appointments.
She shows up when she wants but usually waits less than fifteen minutes to be seen. She then spends as much time with us as she needs, sometimes that’s 40 minutes, usually it’s less than five. She loves this flexibility; it’s how she saw doctors in Somalia. And I love it because I don’t pay staff to do scheduling, and we have zero no-show rate and a zero late-show rate. It makes business sense.
Another difference is our office layout. Our exam rooms open right to the waiting room. Our medical providers room their own patients, and our providers stay in one room instead of alternating between rooms. Cutting steps cuts costs and increases customer satisfaction.
We also hand out free medicines right from our exam room – over-the-counter ones and some prescription ones too. If Nostra’s baby is sick, we put a bottle of children’s Tylenol or Amoxicillin right in her hand. She can take that baby straight back home instead of stopping at the pharmacy. I don’t know about you, but I get sick just looking at all those choices. Nostra doesn’t stand a chance in there. We also text patients.
We’re open evenings and weekends. We do home visits. We’ve jumped dead car batteries. With customer satisfaction so high, we’ve never had to advertise yet are growing at 25% a year. And we’ve become real good at working with Medicaid since it’s pretty much the only insurance company we deal with.
Other doctors’ offices chase ten insurance companies just to make ends meet. That’s just draining. A single-payer system is like monogamy; it just works better. Of course, Medicaid is funded by tax payers like you, so you might be wondering: How much does this cost the system? Well, we’re cheaper than the alternatives. Some of our patients might go to the emergency room, which can cost thousands, just for a simple cold.
Some may stay home and let their problems get worse, but most would try to make an appointment at a clinic that’s part of the system called the Federally Qualified Health Centers. This is a nationwide network of safety net clinics that receive twice as much government funding per visit than private doctors like me.
Not only they get more money, but by law, there can only be one in each area. That means they have a monopoly on special funding for the poor. And like any monopoly, there’s a tendency for cost to go up and quality to go down.
I’m not a government entity. I’m not a non-profit. I’m a private practice. I have a capitalist drive to innovate. I have to be fast and friendly. I have to be cost effective and culturally sensitive. I have to be tall, dark, and handsome. And if I’m not, I’m going out of business. I can innovate faster than a non-profit because I don’t need a meeting to move a stapler.
None of our innovations are new or unique. We just put them together in a unique way to help low income folks while making money. And then instead of taking that money home, I put it back into the refugee community as a business expense. This is Mango House, my version of a medical home. In it, we have programs to feed and clothe the poor, an after school program, English classes, churches, dentist, legal help, mental help, and the Scout groups.
These programs are run by tenant organizations and amazing staff, but all receive some amount of funding from profits from my clinic. Some call this social entrepreneurship. I call it social service arbitrage, exploiting inefficiencies in our healthcare system to serve the poor.
We’re serving 15,000 refugees a year at less cost than where else they would be going. Of course, there’s downsides to doing this as a private business rather than as a non-profit or government entity. There’s taxes and legal exposures. There’s changing Medicaid rates and specialists who don’t take Medicaid, and there’s bomb threats.
Notice there is no apostrophe. So it’s like, “We were going to blow up all you refugees.” We were going to blow up all you refugees, but then we went to your English class instead. Now you might be thinking this guy’s a bit different – uncommon, a communal narcissist, a unicorn maybe – because if this was so easy, then other doctors would be doing it.
Well, based on Medicaid rates, you can do this in most of the country. You can be your own boss, help the poor, and make good money doing it. Medical folks, you wrote on your school application essays that you wanted to help those less fortunate, but then you had your idealism beaten out of you in training, your creativity bred out of you. It doesn’t have to be that way. You can choose underserved medicine as a lifestyle specialty, or even be a specialist who cuts costs in order to see low-income folks.
And for the rest of you who don’t work in healthcare, what did you write on your applications? Most of us wanted to save the world, to make difference. Maybe been successful in your career but are now looking for that meaning? How can you get there? I don’t just mean giving a few dollars or a few hours. I mean, how can you use your expertise to innovate new ways of serving others? It might be easier than you think.
The only way we’re going to bridge the underserved medicine gap is by seeing it as a business opportunity. And the only way we can bridge the inequality gap is by recognizing our privileges and using them to help others.Multi-Page