演講MP3+雙語文稿:醫(yī)生如何幫助低收入病人

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【演講者及介紹】P.J. Parmar

內(nèi)科醫(yī)生，創(chuàng)辦了Ardas Family Medicine（一家為重新安置的難民提供服務(wù)的私人診所），以及Mango House（一家為難民提供活動(dòng)和服務(wù)的機(jī)構(gòu)，包括牙科護(hù)理、食品和服裝銀行、教堂、童子軍和課后項(xiàng)目）。

【演講主題】醫(yī)生如何在盈利的同時(shí)幫助低收入病人

【中英文字幕】

Translation by psjmz mz. Reviewed by Danyang Luo.

00:01

Colfax Avenue, here in Denver, Colorado,was once called the longest, wickedest street in America. My office is there inthe same place -- it's a medical desert. There are government clinics andhospitals nearby, but they're not enough to handle the poor who live in thearea. By poor, I mean those who are on Medicaid. Not just for the homeless; 20percent of this country is on Medicaid. If your neighbors have a family of fourand make less than $33,000 a year, then they can get Medicaid. But they can'tfind a doctor to see them.

科爾法克斯大道位于科羅拉多州丹佛市，曾被稱為美國(guó)“最長(zhǎng)，最邪惡的街道”。我的辦公室就在那兒——那片醫(yī)療資源極度匱乏的地區(qū)。雖然附近有政府診所和醫(yī)院，但根本不夠醫(yī)治這個(gè)地區(qū)的窮人。我所說的窮人是指那些接受醫(yī)療補(bǔ)助的人。不僅指無家可歸的人；美國(guó)有20%的人都接受醫(yī)療補(bǔ)助。如果你鄰居家有四口人，年收入不到33,000美元，那么他們就能獲得醫(yī)療補(bǔ)助。然而他們卻找不到醫(yī)生治病。

00:35

A study by Merritt Hawkins found that only20 percent of the family doctors in Denver take any Medicaid patients. And ofthose 20 percent, some have caps, like five Medicaid patients a month. Othersmake Medicaid patients wait months to be seen, but will see you today, if youhave Blue Cross. This form of classist discrimination is legal and is not justa problem in Denver. Almost half the family doctors in the country refuse tosee Medicaid patients.

梅里特霍金斯公司做的一個(gè)研究發(fā)現(xiàn)，丹佛只有20%的家庭醫(yī)生接受使用醫(yī)療補(bǔ)助的病人。在這20%的醫(yī)生中，有的有數(shù)量限制，比如一個(gè)月看5位醫(yī)療補(bǔ)助病人。有些醫(yī)生則讓使用醫(yī)療補(bǔ)助的病人等上幾個(gè)月，但如果你有藍(lán)十字醫(yī)療險(xiǎn)，你今天就能接受治療。這種階級(jí)歧視是合法的，并且不僅丹佛存在這個(gè)問題。幾乎一半的美國(guó)家庭醫(yī)生都拒絕接收使用醫(yī)療補(bǔ)助的病人。

01:05

Why? Well, because Medicaid pays less thanprivate insurance and because Medicaid patients are seen as more challenging.Some show up late for appointments, some don't speak English and some havetrouble following instructions. I thought about this while in medical school.If I could design a practice that caters to low-income folks instead ofavoiding them, then I would have guaranteed customers and very littlecompetition.

為什么？因?yàn)獒t(yī)療補(bǔ)助支付的金額比私人保險(xiǎn)低，而且人們總覺得接收使用醫(yī)療補(bǔ)助的病人更麻煩。他們有些人會(huì)遲到，有些人不會(huì)說英語，有些人在遵循醫(yī)囑上也存在困難。在醫(yī)學(xué)院時(shí)我就想過這些問題。如果我能設(shè)計(jì)出一個(gè)適合低收入人群而非拒絕他們的醫(yī)療模式那么我的客源就有保證，而且競(jìng)爭(zhēng)很小。

01:35

(Laughter)

（笑聲）

01:36

So after residency, I opened up shop, doingunderserved medicine. Not as a nonprofit, but as a private practice. A smallbusiness seeing only resettled refugees. That was six years ago, and sincethen, we've served 50,000 refugee medical visits.

所以在住院醫(yī)生實(shí)習(xí)結(jié)束后，我開了一家服務(wù)低醫(yī)療服務(wù)水平人群的診所。不是非盈利組織，而是私人診所。一個(gè)小生意，只為重新安置的難民看病。那是在6年前，自那之后，我們已經(jīng)為 5萬難民提供了醫(yī)療服務(wù)。

01:54

(Applause)

（掌聲）

02:02

Ninety percent of our patients haveMedicaid, and most of the rest, we see for free. Most doctors say you can'tmake money on Medicaid, but we're doing it just fine. How? Well, if this werereal capitalism, then I wouldn't tell you, because you'd become my competition.

我們的病人中90%有醫(yī)療補(bǔ)助，對(duì)其他剩下的大部分人，我們提供免費(fèi)診療。很多醫(yī)生說你無法在使用醫(yī)療補(bǔ)助的病人身上賺錢，但我們的收入還不錯(cuò)。如何做到的呢？如果這是資本主義，我可不會(huì)告訴你，因?yàn)槟銈儠?huì)成為我的競(jìng)爭(zhēng)對(duì)手。

02:18

(Laughter)

（笑聲）

02:19

But I call this "bleeding-heart"capitalism.

但我把這稱為“軟心腸”的資本主義。

02:22

(Laughter)

（笑聲）

02:23

And we need more people doing this, notless, so here's how. We break down the walls of our medical maze by taking thechallenges of Medicaid patients, turning them into opportunities, and pocketingthe difference. The nuts and bolts may seem simple, but they add up. Forexample, we have no appointments. We're walk-in only. Of course, that's how itworks at the emergency room, at urgent cares and at Taco Bell.

我們需要更多的人參與進(jìn)來，我們是這么做的。我們把服務(wù)使用醫(yī)療補(bǔ)助的病人的挑戰(zhàn)轉(zhuǎn)化為機(jī)會(huì)，并從中賺取差價(jià)，來解開我們的醫(yī)療謎題。螺母和螺栓看起來很簡(jiǎn)單，但它們加起來卻能發(fā)揮巨大的作用。比如，我們無需預(yù)約。我們采取即到即診的模式。也就是說，急診室和塔可鐘（墨西哥快餐品牌）采用了相同的模式。

02:52

(Laughter)

（笑聲）

02:53

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'tnavigate a phone tree. And she can't show up on time for an appointment becauseshe doesn't have a car, she takes the bus, and she takes care of three kidsplus her disabled father. So we have no appointments; she shows up when shewants, but usually waits less than 15 minutes to be seen. She then spends asmuch time with us as she needs. Sometimes that's 40 minutes, usually it's lessthan five. She loves this flexibility. It's how she saw doctors in Somalia. AndI love it, because I don't pay staff to do scheduling, and we have a zerono-show rate and a zero late-show rate.

但這些在家庭醫(yī)生的辦公室并不常見。我們?yōu)槭裁匆@樣做？因?yàn)橄窦{斯拉這樣的人沒法預(yù)約。她有電話，但她沒錢付話費(fèi)。她不會(huì)說英語，也不會(huì)查詢通訊錄。她無法在預(yù)約時(shí)間準(zhǔn)時(shí)出現(xiàn)，因?yàn)樗龥]有私家車，她需要乘坐公車，并且她需要照顧3個(gè)小孩外加她殘疾的父親。所以我們不提供預(yù)約服務(wù)；她想來的時(shí)候就來，通常等待不到15分鐘就能就診。我們會(huì)充分保證她的就診時(shí)長(zhǎng)。有時(shí)候是40分鐘，但通常不到5分鐘。她喜歡這種彈性。她在索馬里就是這樣看醫(yī)生的。這也讓我很開心，因?yàn)槲也恍枰~外雇人負(fù)責(zé)預(yù)約事項(xiàng)，我們的爽約率和遲到率為零。

03:44

(Laughter)

（笑聲）

03:47

(Applause)

（掌聲）

03:52

It makes business sense.

這很有商業(yè)價(jià)值。

03:54

Another difference is our office layout.Our exam rooms open right to the waiting room, our medical providers room theirown patients, and our providers stay in one room instead of alternating betweenrooms. Cutting steps cuts costs and increases customer satisfaction. We alsohand out free medicines, right from our exam room: over-the-counter ones andsome prescription ones, too. If Nasra's baby is sick, we put a bottle ofchildren's Tylenol or amoxicillin right in her hand. She can take that babystraight 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 chancein there.

另一個(gè)不同是我們辦公室的布局。我們的檢查室和候診室相通，每個(gè)醫(yī)生都和他們自己的病人獨(dú)享一個(gè)房間，我們的服務(wù)人員集中在一個(gè)房間里，而不需要在兩個(gè)房間之間來回穿梭。削減流程降低了成本，提高了客戶滿意度。我們還在診室分發(fā)免費(fèi)藥品：非處方藥和一些處方藥。如果納斯拉的孩子病了，我們會(huì)直接給她一瓶?jī)和┲Z或阿莫西林。她可以直接帶孩子回家，而無需再去藥店。我不知道你們?cè)趺聪耄乙灰姷竭@一大堆藥就頭暈。納斯拉根本沒法在這里買藥。

04:39

We also text patients. We're open eveningsand weekends. We do home visits. We've jumped dead car batteries.

我們也給病人發(fā)短信。我們晚上和周末都營(yíng)業(yè)。我們做家訪。我們把汽車電池都跑到?jīng)]電了。

04:46

(Laughter)

（笑聲）

04:48

With customer satisfaction so high, we'venever had to advertise, yet are growing at 25 percent a year. And we've becomereal good at working with Medicaid, since it's pretty much the only insurancecompany we deal with. Other doctor's offices chase 10 insurance companies justto make ends meet. That's just draining. A single-payer system is likemonogamy: it just works better.

有這么高的客戶滿意度，我們根本不用打廣告，還能以每年25%的速度增長(zhǎng)。我們變得很熟悉Medicaid的業(yè)務(wù)，因?yàn)樗鼛缀跏俏覀兾ㄒ缓献鞯谋ｋU(xiǎn)公司。其他醫(yī)生的診所同時(shí)與10家保險(xiǎn)公司合作以實(shí)現(xiàn)收支平衡，但收效甚微。單一支付方制度就像一夫一妻制: 它就是效果更好。

05:13

(Laughter)

（笑聲）

05:15

(Applause)

（掌聲）

05:19

Of course, Medicaid is funded by tax payerslike you, so you might be wondering, "How much does this cost thesystem?" Well, we're cheaper than the alternatives. Some of our patientsmight go to the emergency room, which can cost thousands, just for a simplecold. Some may stay home and let their problems get worse. But most would tryto make an appointment at a clinic that's part of the system called theFederally Qualified Health Centers. This is a nationwide network of safety-netclinics that receive twice as much government funding per visit than privatedoctors like me. Not only they get more money, but by law, there can only beone in each area. That means they have a monopoly on special funding for thepoor. And like any monopoly, there's a tendency for cost to go up and qualityto go down.

當(dāng)然，醫(yī)療補(bǔ)助計(jì)劃由像你們這樣的納稅人資助，所以你們可能會(huì)好奇，“這個(gè)系統(tǒng)要花多少錢？”我們比主流方案便宜。我們有些病人去急診室，僅僅一個(gè)簡(jiǎn)單的感冒，就要花數(shù)千美元。有些人則呆在家中，坐等問題惡化。但是大多數(shù)人會(huì)嘗試在屬于聯(lián)邦授權(quán)醫(yī)療中心的一個(gè)診所預(yù)約。這是一個(gè)覆蓋全國(guó)的診所安全網(wǎng)絡(luò)，每次看病得到的政府資助是像我這樣的私人醫(yī)生的兩倍。他們不僅收取更高的費(fèi)用，根據(jù)法律，每個(gè)地區(qū)只能有一個(gè)。這意味著他們壟斷了為窮人提供的特殊資金。跟任何壟斷一樣，總是成本會(huì)上升，質(zhì)量會(huì)下降。

06:15

I'm not a government entity; I'm not anonprofit. I'm a private practice. I have a capitalist drive to innovate. Ihave to be fast and friendly. I have to be cost-effective and culturallysensitive. I have to be tall, dark and handsome.

我不是政府實(shí)體，我不是非盈利組織。我是個(gè)私人診所。我有資本主義的創(chuàng)新動(dòng)力。我必須高效和友好。我得有成本效益和文化敏感性。我必須又高又黑又帥。

06:34

(Laughter)

（笑聲）

06:35

(Applause)

（掌聲）

06:37

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 movea stapler.

如果不具備這些，我的生意就會(huì)垮掉。我比非盈利組織在創(chuàng)新方面更高效，因?yàn)槲也恍枰_個(gè)會(huì)來決定是否拆除縫合器。

06:45

(Applause)

（掌聲）

06:51

Really, none of our innovations are new orunique -- we just put them together in a unique way to help low-income folkswhile making money. And then, instead of taking that money home, I put it backinto the refugee community as a business expense.

我們的創(chuàng)新都不是新的或獨(dú)創(chuàng)的——我們只是用一種獨(dú)特的方法把它們組合在一起，在幫助低收入人群的同時(shí)還賺錢。然后，我會(huì)把這些錢投入難民社區(qū)作為商業(yè)支出，而不是拿回家。

07:05

This is Mango House. My version of amedical home. In it, we have programs to feed and clothe the poor, anafter-school program, English classes, churches, dentist, legal help, mentalhealth and the scout groups. These programs are run by tenant organizations andamazing staff, but all receive some amount of funding form profits from myclinic. Some call this social entrepreneurship. I call it social-service arbitrage.Exploiting inefficiencies in our health care system to serve the poor. We'reserving 15,000 refugees a year at less cost than where else they would begoing.

這是芒果屋。我創(chuàng)建的醫(yī)療之家。在那里，我們?yōu)楦F人提供食物和衣服，提供課外項(xiàng)目，英語課，教堂，牙醫(yī)，法律援助，心理輔導(dǎo)和童子軍等項(xiàng)目。這些項(xiàng)目由承租組織和出色的員工運(yùn)作，但他們都從我的診所獲得了一些資金。有人稱之為社會(huì)企業(yè)家精神。我稱之為社會(huì)服務(wù)套利。利用我們衛(wèi)生保健系統(tǒng)的低效率為窮人服務(wù)。我們每年服務(wù)15,000位難民，且比其他地方花費(fèi)更少。

07:53

Of course, there's downsides to doing thisas a private business, rather than as a nonprofit or a government entity.There's taxes and legal exposures. There's changing Medicaid rates andspecialists who don't take Medicaid. And there's bomb threats. Notice there'sno apostrophes, it's like, "We were going to blow up all yourefugees!"

當(dāng)然，作為私人企業(yè)，既非非盈利組織，也非政府實(shí)體，做這個(gè)也有不利的一面。有稅收和法律風(fēng)險(xiǎn)。有不斷變化的醫(yī)療補(bǔ)助率和不接受醫(yī)療補(bǔ)助病人的專家。還有炸彈威脅。請(qǐng)注意，這里少了個(gè)標(biāo)點(diǎn)符號(hào)，所以表達(dá)的意思就變成了，“我們本來要炸掉你們這些難民！”

08:15

(Laughter)

（笑聲）

08:21

"We were going to blow up all yourefugees, but then we went to your English class, instead."

“我們本來要炸掉你們這些難民，但后來我們?nèi)ド狭四銈兊挠⒄Z課。”

08:25

(Laughter)

（笑聲）

08:29

(Applause)

掌聲

08:35

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

現(xiàn)在，你可能在想，“這家伙的確有一套。”

08:38

(Laughter)

（笑聲）

08:39

Uncommon.

罕見。

08:40

(Laughter)

（笑聲）

08:41

A communal narcissist?

一個(gè)公共自戀者？

08:43

(Laughter)

（笑聲）

08:44

A unicorn, maybe, because if this was soeasy, then other doctors would be doing it. Well, based on Medicaid rates, youcan do this in most of the country. You can be your own boss, help the poor andmake good money doing it.

也許還是獨(dú)角獸，但如果這么簡(jiǎn)單的話，其他醫(yī)生也會(huì)這樣做。根據(jù)醫(yī)療補(bǔ)助率，你可以在全國(guó)大部分地區(qū)這樣做。你可以做自己的老板，幫助窮人并賺大錢。

08:57

Medical folks, you wrote on your schoolapplication essays that you wanted to help those less fortunate. But then youhad your idealism beaten out of you in training. Your creativity bred out ofyou. It doesn't have to be that way. You can choose underserved medicine as alifestyle specialty. Or you can be a specialist who cuts cost in order to seelow-income folks.

醫(yī)學(xué)院的人可能在申請(qǐng)學(xué)校時(shí)說過你想幫助那些不幸的人。但你的理想情懷在訓(xùn)練過程中丟掉了。你的創(chuàng)造力不復(fù)存在了。你們本可以做得更好。你可以選擇醫(yī)療服務(wù)不足的領(lǐng)域作為畢生專業(yè)?；蛘吣憧梢赃x擇成為降低成本，為低收入人群看病的專家。

09:22

And for the rest of you, who don't work inhealth care, what did you write on your applications? Most of us wanted to savethe world, to make a difference. Maybe you've been successful in your careerbut are now looking for that meaning? How can you get there? I don't just meangiving a few dollars or a few hours; I mean how can you use your expertise toinnovate new ways of serving others. It might be easier than you think.

對(duì)不從事醫(yī)療保健行業(yè)的其他人來講，你的申請(qǐng)表是怎么寫的？我們大部分人想要拯救世界，改變現(xiàn)狀。你們也許在你們的職業(yè)中已足夠成功，現(xiàn)在正在尋找生活的意義？你如何能夠?qū)崿F(xiàn)那個(gè)目標(biāo)？我指的不是捐獻(xiàn)一些錢或幾個(gè)小時(shí)；我的意思是你如何使用你的專業(yè)技能，以新的方式去服務(wù)他人？這可能沒你想的那么難。

09:51

The only way we're going to bridge theunderserved medicine gap is by seeing it as a business opportunity. The onlyway we're going to bridge the inequality gap is by recognizing our privilegesand using them to help others.

我們能夠彌補(bǔ)醫(yī)療服務(wù)不足的唯一方法是將其視為商業(yè)機(jī)會(huì)。我們縮小不平等差距的唯一途徑是認(rèn)識(shí)到我們的特權(quán)，并利用這些特權(quán)幫助他人。

10:04

(Applause)

（掌聲）