How doctors can help low-income patients (and still make a profit) | P.J. Parmar

57,403 views ・ 2019-02-27

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Translator: Ivana Korom Reviewer: Krystian Aparta
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Colfax Avenue, here in Denver, Colorado,
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was once called the longest, wickedest street in America.
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My office is there in the same place -- it's a medical desert.
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There are government clinics and hospitals nearby,
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but they're not enough to handle 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.
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If your neighbors have a family of four 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
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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.
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Others make Medicaid patients wait months to be seen,
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but will see you today, if you have Blue Cross.
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This form of classist 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
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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
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and because Medicaid patients are seen as more challenging.
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Some show up late for appointments, some don't speak English
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and some have trouble following instructions.
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I thought about this while in medical school.
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If I could design a practice 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.
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(Laughter)
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So after residency, I opened up shop, doing underserved medicine.
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Not as a nonprofit, but as a private practice.
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A small business 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.
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(Applause)
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Ninety percent of our patients 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,
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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,
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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.
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(Laughter)
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And we need more people doing this, not less, so here's how.
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We break down the walls of our medical maze
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by taking the challenges of Medicaid patients,
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turning them into opportunities, and pocketing the difference.
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The nuts and bolts 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,
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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.
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Why do we do it?
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Because Nasra can't call for an appointment.
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She has a phone, but she doesn't have phone minutes.
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She can't speak English, and she can't navigate a phone tree.
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And she can't show up on time for an appointment
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because she doesn't have a car, she takes the bus,
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and she takes care of three kids 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.
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She then spends as much time with us as she needs.
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Sometimes that's 40 minutes, 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,
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and we have a zero no-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,
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our medical providers room their own patients,
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and our providers stay in one room instead of alternating between rooms.
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Cutting steps cuts costs and increases customer satisfaction.
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We also hand out free medicines, right from our exam room:
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over-the-counter ones 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.
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She can take that baby straight back home 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.
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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,
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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,
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since it's pretty much the only insurance company we deal with.
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Other doctor's offices 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.
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(Laughter)
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(Applause)
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Of course, Medicaid is funded by tax payers like you,
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so you might be wondering, "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,
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which can cost thousands, just for a simple cold.
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Some may stay home 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
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called the Federally Qualified Health Centers.
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This is a nationwide network of safety-net clinics
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that receive twice as much 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.
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That means they have a monopoly 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.
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I'm not a government entity; 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.
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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.
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(Applause)
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Really, none of our innovations 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.
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And then, instead of taking that money home,
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I put it back into the refugee community 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,
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an after-school program, English classes,
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churches, dentist, legal help, mental health and the scout groups.
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These programs are run 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.
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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.
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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.
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Of course, there's downsides to doing this as a private business,
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rather than as a nonprofit 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.
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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!"
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(Laughter)
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"We were going to blow up all you refugees,
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but then we went 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."
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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.
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Well, based on Medicaid rates, 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.
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Medical folks,
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you wrote on your school application essays
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that you wanted to help those less fortunate.
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But then you had your idealism 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.
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Or you can be a specialist
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who cuts cost in order to see low-income folks.
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And for the rest of you, 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.
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Maybe you've been 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;
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I mean how can you use your expertise 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
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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
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is by recognizing our privileges and using them to help others.
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(Applause)
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