On a road in Aurora, Colorado, lined with used-car dealers and pawnshops sits a tan, low-rise building called Mango House. Inside, among international-food stalls and ethnic-clothing shops, is a family-medicine clinic that serves a largely refugee and immigrant community. Improbably, the clinic makes enough money to sustain itself and pay staff well without relying on grants or donations. And it does so through Medicaid.
The prevailing wisdom is that Medicaid is a losing proposition for health facilities, an insurance program so stingy that many can’t afford to take it. Some of those that do essentially segregate Medicaid patients into separate clinics. Here, Medicaid is preferred.
Because the clinic relies so heavily on that program, I expected that the Trump administration’s upcoming Medicaid cuts might force Mango House to close or pare back. Instead, when I spoke recently with the clinic’s founder and owner, P. J. Parmar, they were far from his mind. Medicaid’s practices—and patients’ coverage—already fluctuate enough that he and his staff are used to weathering such unpredictable forces. Even if 15 percent of his patients fell off Medicaid because of the cuts, his practice would be fine, he said, showing me his calculations.
Parmar is a family physician who opened the practice—officially named Ardas Family Medicine, but now better known by its location inside Mango House—in 2012. He wanted to reengineer how a clinic could run, designing systems that maximized efficiency and ease of access. For starters, Parmar eliminated scheduled appointments, which he called “an exercise in craziness.” In theory, appointments ensure that people don’t have to wait long to see their doctor, but Parmar found scheduling to be so inherently erratic—some patients need only a few minutes, others half an hour; many don’t show up at all—that he could see more patients, while keeping wait times short, by simply having them walk in. On the Wednesday I was there, the practice hummed along. Medical assistants from Nepal, Myanmar, Somalia, and Afghanistan greeted patients; the average wait time hovered around 10 minutes. Even during the Monday-afternoon rush, Parmar said, waits rarely exceed 30 minutes.
Jimena Peck for The Atlantic
The clinic, located among international food stalls and shops, serves a largely refugee and immigrant community.
Most days of the year (and it’s open all but five), the clinic is staffed with three clinicians—a mix of doctors and nurse practitioners—who together see about 100 patients. Each provider has a dedicated exam room arranged how they like, so they don’t waste time hunting for supplies or shuttling between spaces. They escort patients from the waiting room and perform vital signs themselves: The clinic doesn’t employ nurses. (Lower-cost medical assistants handle routine tasks such as giving shots and drawing blood.) The providers see patients in order of arrival. Of course, some patients still have favorites, so staff will mark any preferences when they check in.
In American medicine, short appointment times are often a cause for complaint. But from what I observed at the Mango House clinic, the ease of access, rather than undue pressure on clinicians, seemed to keep many visits brief. An older woman Parmar has long cared for came in with a cough, and even as he was writing her a prescription, she asked, “Can I go now?” She told him that if she didn’t feel better in a week, she’d just walk into the clinic again. Parmar also deliberately streamlines clinic notes by encouraging his providers to avoid the common habit of copying and pasting blocks of obsolete or redundant information in favor of quick updates that can be scanned easily at subsequent visits. When I described this practice to Asaf Bitton, a Harvard professor and a primary-care researcher, he told me it likely helps clinicians see more patients without feeling overextended.
Jimena Peck for The Atlantic
Parmar’s clinic accepts anyone, but about 70 percent of its patients are on Medicaid.
Small efficiencies add up, for both staff and patients. The morning I was there, a Nepalese man, Gam Sunuwar, chose to fill his prescription for blood-pressure medication at the clinic’s in-house pharmacy, even though he’d need to cut the pills in half. (Better to walk out with what he needed than wait hours at his neighborhood pharmacy for pills in the specific dose.) The pharmacy sometimes operates at a loss, but it helps keep patients loyal to the clinic. Clinicians also hand out dozens of over-the-counter medications and reading glasses for free. Patients sometimes ask the clinic to complete immigration paperwork; Parmar keeps the service cheap (and less tedious for clinic workers) with a computer formula he wrote that pulls vaccine data from the state website into federal immigration forms with one click.
The clinic accepts anyone, but about 70 percent of its patients are on Medicaid. Almost all of the rest are seen for free. Parmar’s two billers are very adept with Medicaid—the only insurer they have to master, unlike others juggling different health plans’ whims. (Parmar himself rattles off Medicaid billing codes like it’s second nature.) Here, private insurance is not desirable, because it can be difficult to get companies to pay up. During my visit, when one patient, a 9-year-old, was registered with a commercial insurance, Parmar pored over its payment sheet without making much sense of it. “In the amount of time we’ve looked at this, we could’ve seen the girl already,” he said. The clinic would bill her insurance, but if the insurer demanded more paperwork, which it likely would, the claim would be abandoned.
The clinic’s ethos—just take care of patients—is both an ethical imperative and a practical tactic to keep the clinic running at full speed. Medicaid patients often cycle off coverage because they forget to renew, or their paperwork never reaches them; Parmar called this “the churn of Medicaid.” Many patients have “no idea” what their insurance is, a status so common that staff use the term in the clinic’s tracking spreadsheet. The staff will try to figure it out, but at some point, it’s not worth haggling over insurance and demanding documents from patients. Pressing for payment could humiliate people, who often arrive with their extended families, Parmar explained, and in a community this close-knit, that could mean losing dozens of patients, including many of the Medicaid patients who keep the clinic afloat.
Jimena Peck for The Atlantic
The pharmacy at Mango House sometimes operates at a loss but helps keep patients loyal to the clinic.
And for a practice that relies on Medicaid, survival is ultimately a “volume game,” Parmar said. That phrase would usually sound ominous in health care: Seeing more patients often means rushed visits and burned-out staff. But the clinic does well on the state’s performance indicators and, from what I observed, is set up so that patients who need extra time get it. Tigist Desta, one of the nurse practitioners, spent the better part of an hour trying to figure out the vaccination status of a child who had just arrived from Ethiopia, for instance.
The clinic had a few lean years in which Parmar lost money—particularly when he bought the old JCPenney building where Mango House is now located—but he has more than made it back. The practice’s profits are considerably higher than the average family physician’s: Parmar told me he puts much of the money back into Mango House. (He opened his QuickBooks for me, but asked that I not publicly share the numbers.) This year, he significantly raised staff salaries; several years ago, he added a dental practice, though it has yet to break even.
When I first heard about Mango House, I was curious whether its model could be duplicated elsewhere. For one, it seemed to offer a glimpse of the kind of health care Americans might experience if the country ever moved toward a single-payer system. I also found its operations appealing, particularly that it seemed to focus on what mattered to patients and doctors rather than to administrators. The simple fact that it’s an independent clinic may be an asset: Some studies have found that physician-owned clinics achieve greater cardiovascular outcomes while also being associated with lower burnout for staff. “More and more primary-care docs work for these big health systems, and they’re not independent business owners,” who are better at seeing more patients and recouping their work on the billing side, Ateev Mehrotra, the chair of health policy at Brown, told me. Parmar can adjust on the fly—he added an extra provider on those busy Monday afternoons, starting the week after I visited—because, as he put it, “there’s no committee looking over me.”
Jimena Peck for The Atlantic
The clinic cultivates a casual, lived-in feel.
But independence can also seem like idiosyncrasy, or merely choosing different corners to cut. At Mango House, patients don’t change into gowns, except for intimate exams, and a patchwork of multilingual staff, family members, and neighbors handles interpretation—an approach that experts oppose because these unofficial translators might not explain medical terms properly or could compromise patient privacy. (Parmar countered that he retired his remote-interpreting service after finding that patients preferred their family and community members—who also often know details they themselves neglect to mention.)
As Katherine Baicker, the provost and a health economist at the University of Chicago, told me, “Often things that work in one setting may not work in another.” In at least 16 other states, Medicaid pays as well or better than it does in Colorado, which could make replication feasible if clinics could get the same volume. But not every state allows medical assistants to give injections, erasing that cost savings. Other patient populations may be more litigious than those served by the clinic, which could pressure providers to order extra tests and unnecessary referrals.
Neither Baicker nor Bitton, the Harvard professor, has studied Mango House, but both see the clinic’s strength as tailoring care to the local community. Bitton thought it probably shared features with the few “bright spots” he has studied—places defined by a “sort of radical simplicity,” he said, where clinicians essentially work within a single-payer system to serve a defined community of patients. Yet that may be exactly what makes Mango House tough to replicate. Parmar himself acknowledged that the clinic’s casual, community-like style might not jibe with every population. He doesn’t bother with satisfaction surveys, anyway; for him, the true measure is how many patients return. For now, it’s more than enough.
