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

Translator: Ivana Korom Reviewer: Krystian Aparta

Translator: Candela Gómez Reviewer: Noelia Bernárdez Alonso

Colfax Avenue, aquí en Denver, Colorado,

considerouse unha vez a rúa máis longa e peor reputada dos EE. UU.

A miña oficina está alí, no mesmo sitio. É un deserto médico.

Colfax Avenue, here in Denver, Colorado,

Preto, hai ambulatorios gobernamentais e hospitais,

mais non bastan para tratar toda a xente pobre da zona.

was once called the longest, wickedest street in America.

Falo da xente cuxo seguro médico é Medicaid.

My office is there in the same place -- it's a medical desert.

Este non é só para os sen teito; o 20 % deste país ten Medicaid.

There are government clinics and hospitals nearby,

Se na familia dos veciños son 4 e gañan menos de 33 000 USD ao ano,

but they're not enough to handle the poor who live in the area.

poden contratar Medicaid.

By poor, I mean those who are on Medicaid.

Mais non poden dar cun médico que os atenda.

Not just for the homeless; 20 percent of this country is on Medicaid.

Un estudo de Merrit Hawkins

descubriu que só o 20 % dos médicos de cabeceira de Denver

If your neighbors have a family of four and make less than $33,000 a year,

atende pacientes de Medicaid.

Dese 20 %, algúns teñen unha cota, duns 5 pacientes de Medicaid ao mes.

then they can get Medicaid.

But they can't find a doctor to see them.

A study by Merritt Hawkins

Outros fanos agardar meses,

found that only 20 percent of the family doctors in Denver

mais se tes Blue Cross, vante atender hoxe.

take any Medicaid patients.

And of those 20 percent, some have caps, like five Medicaid patients a month.

Esta forma de discriminación clasista é legal.

E non é só un problema en Denver.

Others make Medicaid patients wait months to be seen,

Case a metade dos médicos de cabeceira do país

but will see you today, if you have Blue Cross.

rexeitan atender pacientes de Medicaid.

E por que?

This form of classist discrimination is legal

Pois porque Medicaid paga menos que os seguros privados

and is not just a problem in Denver.

e porque atender os seus pacientes é máis complexo.

Almost half the family doctors in the country

refuse to see Medicaid patients.

Algúns chegan tarde ás citas, outros non falan inglés

e outros non seguen ben as instrucións.

Why?

Well, because Medicaid pays less than private insurance

Pensaba nisto cando estaba na facultade de medicina.

and because Medicaid patients are seen as more challenging.

Se puidese crear unha consulta que atenda a xente pobre

Some show up late for appointments, some don't speak English

and some have trouble following instructions.

no lugar de evitala,

daquela tería clientela asegurada e moi pouca competencia.

I thought about this while in medical school.

[Risos]

If I could design a practice that caters to low-income folks

Entón, tras a residencia, comecei a dar atención medica aos desatendidos,

instead of avoiding them,

non como unha ONG, senón como profesional privado.

then I would have guaranteed customers and very little competition.

Cun pequeno negocio que atendía só refuxiados recolocados.

(Laughter)

So after residency, I opened up shop, doing underserved medicine.

Hai seis anos diso

e, dende entón, levamos 50 000 consultas médicas a refuxiados.

Not as a nonprofit, but as a private practice.

[Aplausos]

A small business seeing only resettled refugees.

That was six years ago,

O 90 % dos nos nosos pacientes teñen Medicaid

and since then, we've served 50,000 refugee medical visits.

e, a case todos os demais, vémolos gratis.

(Applause)

Moitos médicos din que Medicaid non dá cartos,

pero a verdade é que nos vai ben.

E como?

Se isto fose capitalismo real, non volo diría,

Ninety percent of our patients have Medicaid,

porque seriades competencia.

and most of the rest, we see for free.

[Risos]

Most doctors say you can't make money on Medicaid,

Pero a isto chámolle capitalismo humanitario.

but we're doing it just fine.

[Risos]

E precisamos máis xente que o faga, non menos.

How?

Well, if this were real capitalism, then I wouldn't tell you,

Así que veña:

because you'd become my competition.

tiramos as paredes deste labirinto médico

(Laughter)

But I call this "bleeding-heart" capitalism.

e aceptamos o desafío dos pacientes de Medicaid,

convertémolo en oportunidades e gardamos a diferenza.

(Laughter)

And we need more people doing this, not less, so here's how.

Os principios poden parecer simples, pero teñen sentido.

We break down the walls of our medical maze

Por exemplo, non damos citas.

by taking the challenges of Medicaid patients,

Só hai que vir.

turning them into opportunities, and pocketing the difference.

Claro que é así como funciona nas urxencias

e no Taco Bell.

The nuts and bolts may seem simple, but they add up.

[Risos]

For example, we have no appointments.

Mais non é o habitual nas oficinas médicas.

We're walk-in only.

Por que o facemos así?

Of course, that's how it works at the emergency room,

Porque Nasra non pode chamar e pedir cita.

at urgent cares and at Taco Bell.

Ten teléfono, mais non ten minutos.

(Laughter)

But not usually at family doctor's offices.

Non fala inglés e non pode falar cun contestador automático.

Why do we do it?

E non pode chegar a tempo a unha cita

Because Nasra can't call for an appointment.

porque non ten coche; ten que coller o bus,

She has a phone, but she doesn't have phone minutes.

coida de tres nenos mais do pai, que é discapacitado.

She can't speak English, and she can't navigate a phone tree.

Polo que non damos citas.

Ela vén cando quere,

And she can't show up on time for an appointment

mais adoita agardar menos de 15 minutos para que a atendan.

because she doesn't have a car, she takes the bus,

Pasa tanto tempo con nós como ela quere.

and she takes care of three kids plus her disabled father.

Ás veces son 40 minutos, normalmente son menos de cinco.

So we have no appointments;

she shows up when she wants,

but usually waits less than 15 minutes to be seen.

Encántalle esta flexibilidade.

É como ía á consulta en Somalia.

She then spends as much time with us as she needs.

E encántame porque non pago persoal para programar as citas.

Sometimes that's 40 minutes, usually it's less than five.

Ademais, ninguén chega tarde nin falta ás citas.

[Risos]

She loves this flexibility.

It's how she saw doctors in Somalia.

[Aplausos]

And I love it, because I don't pay staff to do scheduling,

É un bo negocio.

and we have a zero no-show rate and a zero late-show rate.

Outra diferenza é a disposición das nosas oficinas.

(Laughter)

As salas de exame conectan coa sala de espera.

(Applause)

Os médicos acollen os seus propios pacientes

e quedan nunha soa sala no lugar de cambiar dunha a outra.

It makes business sense.

Another difference is our office layout.

Eliminar etapas elimina custos e aumenta a satisfacción da clientela.

Our exam rooms open right to the waiting room,

our medical providers room their own patients,

Tamén damos medicamentos gratis directos dende a sala de exame,

and our providers stay in one room instead of alternating between rooms.

sen receita e tamén algúns con receita.

Cutting steps cuts costs and increases customer satisfaction.

Se o bebé de Nasra está enfermo,

pómoslle na man unha botella de Tylenol ou de amoxicilina.

We also hand out free medicines, right from our exam room:

Así pode levar o neno directo para a casa, no lugar de pasar pola farmacia.

over-the-counter ones and some prescription ones, too.

If Nasra's baby is sick,

Non sei vós, pero eu póñome malo só de ver tantas opcións.

we put a bottle of children's Tylenol or amoxicillin right in her hand.

Nasra non ten ningunha posibilidade alí.

She can take that baby straight back home instead of stopping at the pharmacy.

Mensaxeámonos cos pacientes.

Abrimos ás tardes e ás fins de semana.

I don't know about you, but I get sick just looking at all those choices.

Facemos consultas na casa.

Facemos arrancar coches sen batería.

[Risos]

Nasra doesn't stand a chance in there.

Cun índice de satisfacción tan alto, non temos nin que facer publicidade.

We also text patients.

Mesmo temos un crecemento do 25 % cada ano.

We're open evenings and weekends.

We do home visits.

We've jumped dead car batteries.

E traballamos moi ben con Medicaid,

(Laughter)

xa que é a única aseguradora coa que traballamos.

With customer satisfaction so high, we've never had to advertise,

Outras oficinas traballan con ata 10 aseguradoras

yet are growing at 25 percent a year.

só para chegar a fin de mes.

Iso acaba por fartar.

And we've become real good at working with Medicaid,

Ter un pagador único é como a monogamia: funciona mellor.

since it's pretty much the only insurance company we deal with.

[Risos]

Other doctor's offices chase 10 insurance companies

[Aplausos]

just to make ends meet.

That's just draining.

Por suposto, Medicaid finánciano contribuíntes coma vós.

A single-payer system is like monogamy: it just works better.

Por iso, estarédesvos preguntando canto lle custa isto ao sistema.

(Laughter)

O certo é que menos ca outras alternativas

(Applause)

Algúns dos nosos pacientes van ás urxencias,

Of course, Medicaid is funded by tax payers like you,

o que custa milleiros só por un arrefriado.

Algúns quedan na casa e deixan que o problema empeore.

so you might be wondering, "How much does this cost the system?"

Well, we're cheaper than the alternatives.

Mais a maioría van intentar pedir cita nun centro que pertence a un sistema

Some of our patients might go to the emergency room,

which can cost thousands, just for a simple cold.

chamado Federally Qualified Health Centers:

Some may stay home and let their problems get worse.

unha rede de centros de último recurso a nivel nacional

But most would try to make an appointment at a clinic that's part of the system

que reciben o dobre de financiamento gobernamental por cita

called the Federally Qualified Health Centers.

que os médicos privados coma min.

Non só reciben máis cartos,

This is a nationwide network of safety-net clinics

senón que, por lei, só pode haber un en cada zona.

that receive twice as much government funding per visit

Polo tanto, teñen o monopolio do financiamento para a xente pobre.

than private doctors like me.

E coma en todos os monopolios,

o custo tende a subir e a calidade a baixar.

Not only they get more money,

but by law, there can only be one in each area.

Non son unha entidade gobernamental, non son unha ONG.

That means they have a monopoly on special funding for the poor.

Son un profesional privado.

Teño unha mentalidade de innovación capitalista.

And like any monopoly,

there's a tendency for cost to go up and quality to go down.

Teño que ser rápido e amable.

I'm not a government entity; I'm not a nonprofit.

Teño que ter prezos competentes e ser tolerante coas diferentes culturas.

I'm a private practice.

Teño que ser alto, moreno e guapo.

I have a capitalist drive to innovate.

[Risos]

I have to be fast and friendly.

[Aplausos]

E se non o son, quedo sen negocio.

I have to be cost-effective and culturally sensitive.

Podo innovar máis rápido que unha ONG,

porque non preciso dunha reunión para mover unha grampadora.

I have to be tall, dark and handsome.

[Aplausos]

(Laughter)

(Applause)

And if I'm not, I'm going out of business.

De verdade, ningunha das nosas innovacións son novas ou únicas,

I can innovate faster than a nonprofit,

because I don't need a meeting to move a stapler.

só as pomos xuntas dunha maneira única

para axudar á xente con poucos recursos mentres gañamos a vida.

(Applause)

E logo, no lugar de levar eses cartos,

invístoos na comunidade de refuxiados como custo asociado.

Really, none of our innovations are new or unique --

Isto é Mango House.

we just put them together in a unique way

A miña versión dun fogar médico.

to help low-income folks while making money.

Nel temos programas para dar alimento e roupa á xente pobre,

And then, instead of taking that money home,

actividades extraescolares, clases de inglés,

I put it back into the refugee community as a business expense.

igrexas, dentistas, axuda legal, saúde mental e grupos de scouts.

This is Mango House.

My version of a medical home.

In it, we have programs to feed and clothe the poor,

Estes programas diríxenos asociacións veciñais

an after-school program, English classes,

e un persoal extraordinario,

mais todos reciben algo de financiamento da miña clínica.

churches, dentist, legal help, mental health and the scout groups.

These programs are run by tenant organizations

Algúns chaman a isto emprendemento social,

and amazing staff,

eu chámoo arbitraxe de servizos sociais.

but all receive some amount of funding form profits from my clinic.

Explotamos as insuficiencias do sistema de saúde pública

para axudar á xente pobre.

Some call this social entrepreneurship.

Atendemos a 15 000 persoas refuxiadas ao ano

por menos cartos que en calquera sitio onde poderían ir.

I call it social-service arbitrage.

Exploiting inefficiencies in our health care system to serve the poor.

Claro que hai desvantaxes de ser un negocio privado,

en comparación coas ONG ou as entidades gobernamentais.

We're serving 15,000 refugees a year

Hai taxas que pagar e riscos legais.

at less cost than where else they would be going.

Hai cambios nas tarifas de Medicaid e especialistas que non aceptan Medicaid.

Of course, there's downsides to doing this as a private business,

E ameazas de bomba.

rather than as a nonprofit or a government entity.

[Imos rebentarvos a todos, refuxiados] Fixádevos como está escrito. É como

There's taxes and legal exposures.

«Imos rebentarvos a todos, refuxiados».

There's changing Medicaid rates and specialists who don't take Medicaid.

[Risos]

And there's bomb threats.

«Iamos rebentarvos a todos, refuxiados,

Notice there's no apostrophes, it's like,

mais logo preferimos ir ás vosas clases de lingua».

"We were going to blow up all you refugees!"

[Risos]

(Laughter)

[Aplausos]

"We were going to blow up all you refugees,

but then we went to your English class, instead."

Se cadra agora pensades «este home é diferente».

(Laughter)

[Risos]

Raro.

[Risos]

(Applause)

Un narcisista comunal?

[Risos]

Quizais un unicornio.

Porque se isto fose tan doado, outros médicos farían o mesmo.

Now, you might be thinking, "This guy's a bit different."

Segundo o índice de Medicaid isto pódese facer en gran parte do país.

(Laughter)

Uncommon.

(Laughter)

Podedes ser o voso propio xefe,

A communal narcissist?

axudar á xente pobre e seguir gañando diñeiro.

(Laughter)

A unicorn, maybe,

because if this was so easy, then other doctors would be doing it.

Colegas médicos,

escribistes nas vosas solicitudes

que queriades axudar aos máis desfavorecidos.

Well, based on Medicaid rates, you can do this in most of the country.

Mais logo vistes o voso idealismo esmagado durante a carreira.

You can be your own boss,

help the poor and make good money doing it.

Perdestes a vosa creatividade.

Medical folks,

Non ten por que ser así.

you wrote on your school application essays

that you wanted to help those less fortunate.

Podedes elixir como especialidade a asistencia sanitaria aos desfavorecidos.

But then you had your idealism beaten out of you in training.

Ou podedes ser especialistas

Your creativity bred out of you.

que abaratan custos para recibir a xente con poucos recursos.

It doesn't have to be that way.

E en canto ao resto de vós, que non traballades na saúde,

You can choose underserved medicine as a lifestyle specialty.

que escribistes nas vosas solicitudes?

A maioría de nós quería salvar o mundo, ter un impacto.

Or you can be a specialist

who cuts cost in order to see low-income folks.

Quizais tedes éxito nas vosas carreiras

mais agora buscades darlle sentido?

And for the rest of you, who don't work in health care,

Como podedes chegar alí?

what did you write on your applications?

Most of us wanted to save the world, to make a difference.

Non digo doar uns poucos cartos ou unhas poucas horas;

refírome a como podedes usar os vosos coñecementos

Maybe you've been successful in your career

para atopar formas de axudar aos demais.

but are now looking for that meaning?

How can you get there?

Quizais é máis doado do que pensades.

I don't just mean giving a few dollars or a few hours;

A única maneira de superar a fenda da atención médica á xente pobre

I mean how can you use your expertise to innovate new ways of serving others.

é véndoa como unha oportunidade de negocio.

A única maneira de superar a fenda da desigualdade

é recoñecendo os nosos privilexios e usándoos para axudar aos demais.

It might be easier than you think.

The only way we're going to bridge the underserved medicine gap

[Aplausos]

is by seeing it as a business opportunity.

The only way we're going to bridge the inequality gap

is by recognizing our privileges and using them to help others.

(Applause)