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

57,484 views ・ 2019-02-27

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00:00
Translator: Ivana Korom Reviewer: Krystian Aparta
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譯者: 于雍 歐 審譯者: Melody Tang
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.
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在美國曾經被稱為是最長 且最邪惡的街道。
00:22
My office is there in the same place -- 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。
00:26
There are government clinics 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.
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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.
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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。
00:38
If your neighbors have a family of four 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,
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
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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.
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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。
00:59
Others make Medicaid patients 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。
01:02
but will see you today, 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。
01:06
This form of classist 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
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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
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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,
01:21
and because Medicaid patients 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。
01:26
Some show up late for appointments, 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.
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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.
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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
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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,
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.
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我會有客源的保障, 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.
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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。
01:53
Not as a nonprofit, 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。
01:56
A small business 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。
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.
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至今,我們已經做了 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,
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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,
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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,
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,
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如果我是純資本主義者, 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.
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我把這個稱為 「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.
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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。
02:40
We break down the walls 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,
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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.
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將它們轉變為機會 並且從其中獲得利潤。
02:50
The nuts and bolts 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。
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,
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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。
03:04
(Laughter)
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(笑聲)
03:05
But not usually 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.
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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.
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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.
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她不會講英文 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
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她無法準時在預約時間到診所,
03:23
because she doesn't have a car, she takes the bus,
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因為她沒有車,她只能搭乘巴士。
03:26
and she takes care of three kids plus her disabled father.
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她要照顧三個孩子, 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.
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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.
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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.
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有時候會花四十分鐘, 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,
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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。
03:53
and we have a zero no-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,
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我們的候診室直通檢查室,
04:11
our medical providers 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.
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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。
04:19
Cutting steps cuts costs 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。
04:24
We also hand out free medicines, 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.
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不管是非處方藥 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.
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我們直接遞給她一瓶兒童泰勒諾 (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.
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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。
04:43
I don't know about you, but I get sick 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。
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,
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因為顧客滿意度極高 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,
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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.
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因為它幾乎是 我們唯一合作的保險公司。
05:14
Other doctor's offices 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,
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.
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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。
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,
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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,
05:35
so you might be wondering, "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?」
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,
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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.
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可能要花幾千元 就只是為了一個小感冒。
05:46
Some may stay home 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。
05:50
But most would try to make an appointment 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。
05:56
called the Federally 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
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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
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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,
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.
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根據法律,每個區域 只能有一個這種診所。
06:16
That means they have a monopoly 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。
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.
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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.
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我不是政府單位, 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.
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我必須要有成本效益 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。
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.
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因為我不需要為了 移動一個釘書機去開會。
06:57
(Applause)
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07:03
Really, none of our innovations 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,
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.
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以幫助低收入的民眾 同時也賺到錢。
07:11
And then, instead of taking 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.
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而是將賺的錢當作事業支出 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,
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在那裡我們有方案 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.
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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。
07:33
These programs are run 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.
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這些人只有從我診所的 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.
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利用我們健康照護系統的 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.
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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。
08:05
Of course, there's downsides 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.
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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.
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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。
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
08:25
"We were going to blow up 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,
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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."
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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."
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你現在可能會想 「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)。
08:57
because if this was so easy, 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。
09:01
Well, based on Medicaid rates, 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。
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.
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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
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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.
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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.
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但是在你的培訓過程中 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。
09:24
You can choose underserved medicine as a lifestyle specialty.
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你可以選擇提供服務 給醫療不足的人做為你的生活方式。
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.
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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,
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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.
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大多數的我們都想拯救世界, 並做出改變。
09:43
Maybe you've been 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;
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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.
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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。
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
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唯一可以減少 醫療服務不足的方法是
10:06
is by seeing it as a business opportunity.
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將這視為你生意的機會。
10:08
The only way we're going to bridge 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.
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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)
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