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

Translator: Ivana Korom
Reviewer: Krystian Aparta Colfax Avenue, here in Denver, Colorado, was once called the longest,
wickedest street in America. 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. Not just for the homeless;
20 percent 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 percent
of the family doctors in Denver take any Medicaid patients. And of those 20 percent, 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? Well, 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. (Laughter) So after residency, I opened up shop,
doing underserved medicine. Not as a nonprofit,
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. (Applause) Ninety percent 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? Well, if this were real capitalism,
then I wouldn’t tell you, because you’d become my competition. (Laughter) But I call this
“bleeding-heart” capitalism. (Laughter) And we need more people doing this,
not less, so here’s how. We 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. (Laughter) But not usually
at family doctor’s offices. Why do we do it? Because Nasra 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. And 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 15 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 a zero no-show rate
and a zero late-show rate. (Laughter) (Applause) 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 Nasra’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. Nasra 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. (Laughter) With customer satisfaction so high,
we’ve never had to advertise, yet are growing at 25 percent 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 doctor’s offices
chase 10 insurance companies just to make ends meet. That’s just draining. A single-payer system is like monogamy:
it just works better. (Laughter) (Applause) 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 nonprofit. 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. (Laughter) (Applause) And if I’m not, I’m going out of business. I can innovate faster than a nonprofit, because I don’t need a meeting
to move a stapler. (Applause) Really, 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 health and the scout groups. These programs are run
by tenant organizations and amazing staff, but all receive some amount of funding
form profits from my clinic. Some call this social entrepreneurship. I call it social-service arbitrage. Exploiting inefficiencies in our
health care 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 nonprofit
or a 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’s no apostrophes, it’s like, “We were going to blow up
all you refugees!” (Laughter) “We were going to blow up
all you refugees, but then we went
to your English class, instead.” (Laughter) (Applause) Now, you might be thinking,
“This guy’s a bit different.” (Laughter) Uncommon. (Laughter) A communal narcissist? (Laughter) 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 you can be a specialist who cuts cost in order to see
low-income folks. And for the rest of you,
who don’t work in health care, what did you write on your applications? Most of us wanted to save the world,
to make a difference. Maybe you’ve 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. The only way we’re going to bridge
the inequality gap is by recognizing our privileges
and using them to help others. (Applause)


  1. Shruti Surati
    Shruti Surati February 27, 2019

    Second one

  2. Ekta Batra
    Ekta Batra February 27, 2019


  3. wildest dream
    wildest dream February 27, 2019

    Nice topic…

  4. max well
    max well February 27, 2019

    Thank you for sharing…..learn a lot

  5. Rich
    Rich February 27, 2019

    Get government out of the way so it stops driving up prices

  6. Shivam Gupta
    Shivam Gupta February 27, 2019

    Love Ted talk… Worth listening.

  7. Lord.L.
    Lord.L. February 27, 2019

    первый нах

  8. Recetas María Caracola
    Recetas María Caracola February 27, 2019

    They share excellent experiences… 👌🤗

  9. Joar
    Joar February 27, 2019

    This is just amazing, inspiring work!

  10. Matthew Iverson
    Matthew Iverson February 27, 2019

    Medicare-for-all would have relieved me of soo much suffering after being rear ended in a car accident.

    Our system sucks. My society failed me.

  11. 凌蘭
    凌蘭 February 27, 2019

    Learn english but still dont know how to talk fluent…

  12. John Armstrong
    John Armstrong February 27, 2019

    Alternatively the state could provide free heath care.

  13. shivangi singh
    shivangi singh February 27, 2019

    This is exactly how most of the local clinics in India work

  14. Matt Roberts
    Matt Roberts February 27, 2019

    The only (real and workable) solution for America is Medicare for all (to ensure no one goes without healthcare), this video just proves it

  15. shivangi singh
    shivangi singh February 27, 2019

    Btw how do they handle the language barriers?

  16. MP Sniper
    MP Sniper February 27, 2019

    I didn't get the point
    what is his way to be efficient for all patients

  17. Sarah Cp
    Sarah Cp February 27, 2019

    Need a doctor in Mesquite Texas, but where? I get We Don't Take SSDI or Not Taking New Patients

  18. Fireside Chat/ Mama Dee
    Fireside Chat/ Mama Dee February 27, 2019

    Low income are blessed that Doctors won’t see us because we bypassed the Opioid Epidemic! HALLELU Yah!!!

  19. mhtinla
    mhtinla February 27, 2019

    Why does this guy discriminate non-refugee low-income patients?

  20. Brenda Rua
    Brenda Rua February 27, 2019

    He does home visits? I thought that was a long gone art. Single payer too. I love how he thinks.

  21. Filipe Almeida
    Filipe Almeida February 27, 2019

    The US is the only developed nation on earth where a talk with this theme would make the least bit of sense.

  22. TidalWave Dan
    TidalWave Dan February 27, 2019

    A doctor has zero inventory, so their overhead is nil. A doctor makes a profit simply by going to work. Greed has gotten ahold of the most important aspects of any community. Government, schools, and health.

  23. abdelaziz gd
    abdelaziz gd February 27, 2019

    that was one of great speech, it proves that we can be less greedy and still can make enough money.. this kind of thinking must be generalised and applied in all fields.. salutation from Morocco 👏👏

  24. Tony Ray
    Tony Ray February 27, 2019

    As long as their bottom line is money and making a profit then you will never be anything more than a commodity

  25. mhtinla
    mhtinla February 27, 2019

    Why is single payer system more like a monogamy than monopoly?

  26. Graham Jonathan
    Graham Jonathan February 27, 2019

    So glad i live in the UK & we don't have these profit making issues regarding our health

    Its called the NHS and we love it

  27. Mark Young
    Mark Young February 27, 2019

    My biggest issues as a psychotherapist, why I quit taking new medicaid: 1.) MUCH higher no-show rates (w/ least likelihood of apologies, statistically; in our line of work we lose ONE HOUR of clinic time) which the stupid medicaid laws ENCOURAGE because they FORBID ANY behavioral consequence for the patient other than termination of care. Ex., other patients have to pay approx. 25% of the session cost (increases each subsequent missed appointment), which greatly reduces no-shows/late cancels, but it is ILLEGAL for me to impose ANY consequence (other than passive aggressive scheduling delays, which INCREASE likelihood of patient forgetting and no-showing again!). We are not allowed to require or ask the repeat no-show patient volunteer an hour at their child's school, church or animal shelter. 2.) Terrible administration resulting in TAKE BACKS where they wrongly told me someone had coverage, and 5 months later determined they were wrong, and took back all the payments during that period. 3.) Unannounced AUDITS where they took back 100% of visits provided to two brothers because I didn't provide their charts (they were combined at the time w/ some portions at my home office due to a child protective service report I was working on. Way too much work and stress… took me 20+ years to finally drop out, but the last year was insult to injury. Notice I haven't even mentioned that the reimbursement rates are well under half of our already low regional rates; that has never been a big concern of mine, though that means I LOSE > 50% even when MA patients show. The system needs reform re: allowing (even mandating) some modest, affordable COPAYS (even a buck or two makes people appreciate things more, and CONSEQUENCES for failed appointments. For non-MA indigents in group therapy, I used to charge something like $2/session and had members choose a charity that it would go to. Attendance was much better.

  28. Sam Stone
    Sam Stone February 27, 2019

    Do you have enough time to write medical support letters or all you offer walkin appointments, smile and aspirin?

  29. Ghada X
    Ghada X February 27, 2019

    Very inspiring..

  30. James W.
    James W. February 27, 2019

    medicade doesn't just pay less they often take years to pay , and I like how he made having choices into a bad thing because then you have to choose something… if you want cheaper doctors visits find one who takes cash and just bypass the insurance its often 20% -50% cheaper

  31. James W.
    James W. February 27, 2019

    a capitalist drive that only takes taxpayer dollars….

  32. shilajit chowdhury
    shilajit chowdhury February 27, 2019

    this is what IT means to be a TRUE HUMAN….

  33. Freaking Insecure Neurotic and Emotional Iᗰ ᖴIᑎE
    Freaking Insecure Neurotic and Emotional Iᗰ ᖴIᑎE February 27, 2019

    Thank you 🙏💗💗

  34. Octo Girl
    Octo Girl February 27, 2019

    I am so happy I live in Canada.

  35. Don Gemus
    Don Gemus February 27, 2019

    It is not classist nor discriminatory to want to keep your doors open. At my clinic we get 10% to 25% for state insurance versus commercial…. Sometimes less.

    This guy is running a charity with a business mask. Don't cut down the businesses that are keeping the country afloat.

  36. Otterface
    Otterface February 27, 2019

    Universal healthcare. Thank you. End of ted talk.

  37. Koozomec
    Koozomec February 27, 2019

    Step one : take the money.
    Step two : kill the patient.
    Step three : profit.

  38. 0004107 Bemidji
    0004107 Bemidji February 27, 2019

    Thought it was Barrack Obama from the small thumbnail view

  39. Ultimate Spider-man
    Ultimate Spider-man February 27, 2019

    that is a miracle thank you sooooooooo much

  40. Ultimate Spider-man
    Ultimate Spider-man February 27, 2019

    i truly don't understand why amricans suffers paying so much for edu & health care more than any other nation while they pay their taxes 4 Israil & Israil have both health care &edu 4 free

  41. Keith Woodhall
    Keith Woodhall February 27, 2019

    Healthcare should under no circumstances be a for profit venture. Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.

  42. Elliot
    Elliot February 27, 2019

    Awesome 👏

  43. robobrain10000
    robobrain10000 February 27, 2019

    This guy, this guy has a good sense of humor.

  44. Ahmed Lashen
    Ahmed Lashen February 27, 2019

    As a medical student in Egypt, that's truly inspiring. Wish me good luck !!

  45. Fancy Pants
    Fancy Pants February 27, 2019

    Incoming swarm of capitalists arguing that poor people should just die

  46. JESUS Anchor of my SOUL KatherineT
    JESUS Anchor of my SOUL KatherineT February 27, 2019

    I ♥️and respect him🙌🏼🙋🏼‍♀️💯

  47. narutodssunny
    narutodssunny February 27, 2019

    We need Medicare for all.

  48. Scott
    Scott February 27, 2019

    In all western nations except the US, this isn’t even a topic. Because in those nations EVERYONE is just a patient. Income doesn’t matter. No matter what income you generate, they all have the same coverage. For profit healthcare is what makes the US a less than desirable place to live. I live 20min from Canada. Seeing what they don’t have to deal with, verses what we do is sad. Just crossing the border into Canada, you feel the stress level of the people drop dramatically.

  49. iloveyouamberappel
    iloveyouamberappel February 28, 2019

    They show up late and don't follow instructions. No wonder doctors don't want them. For the majority the fact is they are on medicaid for BS just like this.

  50. Deb J
    Deb J February 28, 2019

    Health care is a human right. When is this country going to join the rest of the civilized world?

  51. sahtification
    sahtification February 28, 2019

    Ideas worth spreading for sure

  52. Kyle Johnson
    Kyle Johnson February 28, 2019

    A lot of Japanese hospitals work this way too. People go like it's a doctor's office, and walk-ins are welcome.

  53. kili kilian
    kili kilian February 28, 2019

    So how exactly does he make profits?

  54. Sabryna Alexi
    Sabryna Alexi February 28, 2019

    Wow….this really inspired me

  55. hannah fulton
    hannah fulton February 28, 2019

    There you have it… This sustains me.

  56. Trainable Monkey
    Trainable Monkey February 28, 2019

    One of the best innovations in business I have seen in a long time. I read from the comments this is normal in other countries. At first when he said no appointments, I thought only the sickest will wait but the wait time is 15 minutes. I have Blue Cross and all clinics in my area ask that you arrive at least 15 minutes early.

  57. Aaron Wesly
    Aaron Wesly February 28, 2019

    This is India already

  58. SEAN S
    SEAN S February 28, 2019

    Kinda explain why americans spend highest medical expenditure per capitar (20% higher than second Swizerland ❩ in the world, but only ranked #53 on average life expentancy. Shame on country's medical system. Insurance companies are another factor joint ventured this currpted system. In last year country's top five medical insurers revenue subpassed FAANG total revenue combined. Crap.

  59. Souma Yah
    Souma Yah February 28, 2019

    Wish you good luck buddy 💪💪 you re unique & inspiring ❤

  60. Emiliano Caprili
    Emiliano Caprili February 28, 2019

    Interesting, practically he invented the healthcare system that we Italians adopted more than one hundred years ago.

  61. Leo Fitzpatrick
    Leo Fitzpatrick February 28, 2019

    Laughing in UK

  62. Brian Kagimu
    Brian Kagimu February 28, 2019

    This is very innovative

  63. Thế Giới Nghệ Sĩ THỜI SỰ TV
    Thế Giới Nghệ Sĩ THỜI SỰ TV February 28, 2019

    good job….

  64. Alex Morrison WX
    Alex Morrison WX February 28, 2019

    He has some amazing ideas! We really need to talk about what he does and how to make healthcare for everyone a reality!

  65. Prabu Selvam
    Prabu Selvam February 28, 2019

    Great work! A model for us all to support

  66. Ms. Beerus
    Ms. Beerus February 28, 2019

    I have alot of respect for this dude!

  67. nonchalantd
    nonchalantd February 28, 2019

    8:21 savage

  68. We the Internet TV
    We the Internet TV February 28, 2019

    Dr. P.J. Pamar, who owns a private practice, speaks out against monopolies in health care–"there's a tendency for costs to go up and quality to go down"–but also says, "A single-payer system is like monogamy–it just works better." 🤔

  69. Frejky
    Frejky February 28, 2019

    How doctors can help low-income patients: Vote for Bernie.

  70. satish anil nair
    satish anil nair February 28, 2019

    In America this might seem like an innovation….But this is how general practitioners work in India minus having to deal with medicaid.

    That Indians are not too fond of medical insurance is exactly why medical costs for minor diseases are very reasonable in India…… People directly pay the bills instead of greedy insurance companies acting as middle men. This means the system has a natural check against medical costs spiraling out of control like in the U.S.

    The U.S have a true free market in medical sector where people directly paid their bills for non-emergency care instead of the oligopoly of insurance companies and having a single payer system just for emergencies will give it the best of both worlds.

  71. Mr Chains
    Mr Chains February 28, 2019

    After a long time, a TED talk worth listening.

  72. Gwang Wanwadee
    Gwang Wanwadee March 1, 2019

    Love it …

  73. StatikVerse The Shock
    StatikVerse The Shock March 1, 2019

    I need to send this to my doctor

  74. Oman Gulf
    Oman Gulf March 1, 2019


  75. Prudvidhar Reddy Thangella
    Prudvidhar Reddy Thangella March 1, 2019

    This is how patients are treated in India, in every village, town and city…

  76. Jinsoo Choi
    Jinsoo Choi March 2, 2019

    Wow. just wow.

  77. The Happy Elephant
    The Happy Elephant March 3, 2019

    Did anyone think that that "bomb threat" looked fake?

  78. Pixella
    Pixella March 3, 2019

    … I don't need a meeting to move a stapler . LOL

  79. Mahela Munasinghe
    Mahela Munasinghe March 3, 2019

    In Sri Lanka, health care is free. Sure, facilities aren't top of the range and hospitals get overcrowded but at least everyone gets taken care of. 🙂

  80. FunBotan
    FunBotan March 4, 2019

    This video is the perfect representation of what TED is. Whatever way you choose to interpret this.

  81. FunBotan
    FunBotan March 4, 2019

    Imaging living in US and having problems like this

  82. mmisbach
    mmisbach March 5, 2019

    20% of population is on medicaid. Half of doctors refuse medicaid patients. Under-served medical practice focusing on refugees and low income. Takes no appointments. Gives over-counter medicines for free. Texts patients, and open evenings and weekends. Social service arbitrage. Use your expertise to innovate in new ways to serve. #TedTalk

  83. aleks kensington
    aleks kensington March 5, 2019

    reminds me of new Amsterdam the tv show

  84. Jevon Shepherd
    Jevon Shepherd March 8, 2019

    TRUMP 2020

  85. J G-W
    J G-W March 10, 2019

    Hmmm… I went to a FQHS facility in my town when I didnt have insurance and couldnt afford "regular doctor" and they quoted me over $250 just to see someone for the first time, no tests or diagnostics included. I was making less than $500 a month with no other household income at the time. Maybe they should be investigated or maybe the free/sliding scale of FQHS is bogus?…

  86. hunner
    hunner March 11, 2019

    Life is about helping each other achieve dreams, money seems to really just divert that
    I wanted to be a doctor growing up since to me it was the closest thing to a savior not to desperately hoard wealth
    Money had other plans, lol

  87. theindian mom
    theindian mom March 12, 2019

    Loved it…right in my backyard 😁

  88. Kari Rakitan
    Kari Rakitan March 12, 2019

    I was going to share this until the monogamy comment. As a polyamorous person, you have offended me, sir. Aside from that, your analogy doesn't even make sense. Each doctor sees multiple patients, not one.

  89. Dan Nguyen
    Dan Nguyen March 13, 2019

    One of the reasons why health care in America is so expensive because doctors are in debt so much after finishing their school. In average each owes at least $500K.

  90. Evren Bekdaş
    Evren Bekdaş March 15, 2019


  91. Ravindra Nath
    Ravindra Nath March 19, 2019

    Amazing Concept for serving poor in USA.

    I wish we could do something like that in India but it won't work because unlike USA, in India almost 90% of the healthcare facilities accepts walk-in-patients.

  92. Gypsy Foster
    Gypsy Foster March 22, 2019

    Do the poor Americans not on Medicade get to access this awesome system too ? (I’m a Aussie so not to sure so I’m sorry to ask 😬)
    It would be wonderful if it helps everyone that can’t afford and needs medical care, medications and help. Thanks for the awesome work you’re doing.
    Always ways to change and make things better and this you’ve proven extremely well. Good on you !! 🥰

  93. Angela Sealana
    Angela Sealana March 22, 2019

  94. Heksedans D.
    Heksedans D. March 30, 2019


  95. Pedro Luiz Amaro
    Pedro Luiz Amaro March 31, 2019

    In fact the basic health that should be the most prioritized, is always the one that is left to lad by the authorities

  96. Raven von Frankenstein
    Raven von Frankenstein April 25, 2019

    I sure hope, for the sake of whomever wrote that bomb threat, that their chemistry skills are better than their spelling skills; otherwise, they're going to be missing fingers.

  97. rock rdx
    rock rdx June 18, 2019

    Any doctor can see patient any country

  98. meme youyou
    meme youyou June 23, 2019

    6:50 "I dont need a meeting to move a stapler" LOL

  99. DrTLGardner
    DrTLGardner July 2, 2019

    OMG, your video is an answer to prayer in helping me for when I open my clinic. God bless you! 🙌

  100. Ngọc Anh Hoàng
    Ngọc Anh Hoàng August 13, 2019


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