Walking into Ardas Family Medicine just outside Denver, Colorado, feels like walking into another country. Or a few different countries all at once. During the clinic's late-morning rush on a recent Friday, the waiting room was half-full of patients wearing various head coverings, vibrant-colored dresses and speaking no fewer than four languages. Just as it became clear that one woman couldn't understand a receptionist's question, another young woman entered and checked in for her own visit. "You speak Nepali, right?" the receptionist asked her, and after a nodded response, asked her to translate between herself and the older woman waiting. Problem solved.
It's a typical Friday at Ardas, a clinic in Aurora that exclusively serves refugees; Aurora has become a hub in recent years for refugee resettlement in Colorado. P.J. Parmar, owner and founder of the clinic, says 90 percent or more of Ardas' patients are on Medicaid. Unlike many providers for low-income patients, Ardas does not seek state funding or grants. Instead it operates on a for-profit model; unlike many private family practices, which will treat only a handful of Medicaid patients per month on account of the reimbursement rate being so low, Ardas welcomes them with open arms.
Parmar credits the success of his clinic, now five years old, to its efficiency and willingness to serve the refugee community. But he feels people still see Ardas as a health-care unicorn, rather than a model to replicate. "Most people laugh at this. Not only do other doctors not want Medicaid rates, they don't want Medicaid patients—they're more complicated, they think they're dirty or smelly," he says. "But if you design it from the viewpoint of the people themselves, you not only provide better services for them, you do so profitably."
That's what seems to set Ardas apart: Rather than integrate refugees into a practice that's really designed for a different kind of patient pool, it places them front and center. The clinic is structured to offer a community-oriented practice that, at least more than most operations in the United States, resembles what people had in their home countries. "At least a couple times a week, someone says this feels just like Africa," Parmar says of the clinic. Ardas doesn't take appointments, for example—a practice many are used to, and one that also eliminates barriers that some might face (such as costly cell phone minutes) in the very process of trying to schedule visits. The staff works closely with translators, and a playroom sits next to the patient waiting room to make visits easier for families without child care. Parmar adds, "Family medicine is more about the family than the medicine, and here we know the family."
Catherine M., who fled the Democratic Republic of Congo for a refugee camp in Rwanda in 1996 and came to Colorado in 2008, has been going to Ardas for years for the same reason many of her friends also seek treatment there. "I know many, many people who like Dr. P.J.," she says. "I can say, 'P.J., I have a problem.' If he can't help, he'll call someone who can. If you speak English, if you don't speak English, P.J. can help you."
Another patient from Nepal says many of her friends and family members all go to Ardas for care. Despite having other options, she says, "they feel comfortable here."
The clinic may also be more resilient than other providers in the face of possible changes to Medicaid that have been floated by Republicans in D.C., both independently and as part of the now-failed bill proposed to replace the Affordable Care Act.
"These are folks whose lives have been uprooted in an enormous way, and they're attempting to adapt, find stability in their lives."
Refugees aren't singled out by cuts that have been proposed to Medicaid—it's vulnerable populations in general that are at risk—but they could be disproportionately affected by them.
"These are folks whose lives have been uprooted in an enormous way, and they're attempting to adapt, find stability in their lives," says Joe Sammen, executive director of the Colorado Coalition for the Medically Underserved. "When they're settled in the U.S., in Colorado, their health we know is impacted by more stress—from being in a place that they don't know, language barriers, access to transportation, and other factors that are out of their control. They're already dealing with that sort of uncertainty and the Medicaid program is one thing that allows them to have a little bit of stability."
The clinic currently logs about 1,200 visits per month, and has been growing between 30 and 50 percent per year—because of demand from patients who choose to get care at Ardas, rather than are assigned there. That, he says, is part of why he believes his model is so effective—without the guarantee of business from refugee referral agencies, he has greater incentive to make sure his patients are happy. "We have to be on our game," he says, explaining he makes sure his staff is friendly and accommodating and that patients feel comfortable and welcome, in addition to healthy.
Ardas works because of those efforts and the attention that Parmar and staff pay to efficiency and detail. He has eliminated what he describes as inefficiencies in the U.S. health-care system, focusing instead on seeing as many patients as he can who need him. He says the reimbursement rate he gets per patient is less than half of what most practices serving refugees—and which depend on state-funded programs that Ardas doesn't participate in—get, but he estimates he sees three or four times the volume of patients.
He has figured out what the patient flow generally looks like, and beefs up his office staff during peak rush times—like that recent Friday morning—and pares down for when patients predictably taper off. In the process, he's able to accommodate people in a way they're comfortable with—and provide them much-needed treatment, which is one of the few ways he says refugees are unique in terms of their needs as patients. It's not that they have complicated medical conditions, or that they show up late for appointments; if anything, what sets refugee patients apart are straightforward health issues that have been long neglected. "Being able to help people with issues they've never had a chance for help with, I think that's a difference in the refugee population," Parmar says. "That's one reason I do this work."
Sammen says the risk of Medicaid cuts has a compound effect on refugees because of the current political climate around immigration in general. "It's happening at the exact same time as this massive movement at the federal level, and state level, to sort of villainize and criminalize refugees and immigrants," he says. "We know that refugees and immigrants are not seeking health-care services that they otherwise would have, because of mistrust and fear of the institutions." And, ultimately, foregoing preventive care leads to more burdensome and expensive care down the road.
"We know that refugees are not seeking health-care services that they otherwise would have."
If Medicaid does face cuts along the lines of those proposed in the recently failed legislation, the impacts could be huge. "We'd be getting less money, and there are three things you can do—find new efficiencies, cut benefits, so maybe offer fewer exams, or you can lower what you can pay providers," says Emily Johnson, a policy analyst at the Colorado Health Institute.
Jan Jenkins, director of the Colorado Refugee Wellness Center, is particularly concerned about the potential rollback of people who only recently qualified for Medicaid, such as adults without dependent children, because of the specific and urgent needs of refugees. The health of a single adult male refugee, for example, can look vastly different from that of a typical adult American male. "Some of these folks have been through torture, have had major losses in their families because of war, and were very much in need of care," she says. "What we've seen is it's been hugely important to have everybody covered."
At Ardas, Parmar wouldn't expect much to change even if Medicaid funding does get cut. "I don't see us limiting who we serve. We're just going see them for free and make less money on the rest," he says, estimating that at current reimbursement rates, he could afford to see up to around a third of his patient pool for free.
It's a unique approach to health care that seems to truly place patients before profit, and whether or not Ardas could be seen as replicable is entirely dependent on others being willing to take on the same approach. It's ultimately a question of how much profit doctors, clinic directors, or other decision-makers decide they need to take home.
"Anybody can take Medicaid patients if they just make less money," he says. That may not be a particularly popular goal for professionals, but it does underscore that it's possible to treat more underserved patients, and to serve them better—if that's a priority. "It's called underserved because no one else is doing it."