Are the Uninsured Crowding Our EDs?

[WilcoWorld]

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According to this study in Annals (http://www.annemergmed.com/webfiles/images/journals/ymem/ejweber.pdf) while ED census increased from 1997 to 2004 the % of uninsured patients was stable, wheras the % of patients with income >4x the poverty level and those who usually got care at an office increased significantly.

Surprised? I was.

Now that I think about it, there do seem to be a disproportionate number of people sent to the ED from clinics "to get checked out". Just yesterday I had a healthy 17 year old male with vomiting, diarrhea, chills, and epigastric abdominal pain - who was taking PO, had normal vital signs & a benign belly - sent to our ED, "Because you have a children's hospital & he might need to see a specialist."

Well, to be fair, if you define specialist as someone who sees a heck of a lot of a particular diagnosis, then I guess I would qualify as a specialist in mild to moderate, self-limited gastroenteritis.

Any other thoughts on explanations behind this trend?

 

[emtcsmith]

I think the biggest problem is insurance in general. Why is the system set up so that these companies have such a high control over the prices, and in turn lawyers and other issues cause hospitals to charge more.

The entire idea that you give John Q. System Abuser "universal coverage" for the 20 times he goes to the ED a month for toe pain means only that everybody else pays more because he isn't ever going to pay, let alone contribute to society.

 

[docB]

Clinics dump an excessive number of their patients into the ED. Most of these are inappropriate. I see several issues that lead to dumps:

• Convenience- We get tons of dumps between 3 and 6 pm. Clinic is closing and this patient is still here so it’s off to the ED.
  
• Convenience- PMDs have to seed ~6 patients per hour to make up for the egregiously low reimbursement for an office visit. If whatever you need will take more than 5 minutes (you get 10 minutes total but that includes reading your chart, writing your scripts and writing in your chart too) it's off to the ED.
  
• Convenience- The patient needs some test and getting it cleared through the insurance company’s Byzantine pre-approval process will take time and effort. How to get it done fast and easy? Off to the ED with you!
  
• Convenience- The patient needs to be admitted but writing orders, checking with bed board and, again, negotiating the pre-approval process means time and effort. Go to the ED.
  
• Convenience- Minor lacerations, abscess I&D, IV hydration, LPs, splinting, enemas, etc. can be done in an outpatient clinic. But they are time consuming so it’s off to the ED.
  
• Convenience- No room on the schedule in clinic? Patients calling with new complaints? Just send them to the overflow clinic, um… I mean the ED.
  
• Liability- The PMD wants someone else to touch the patient before they go off into the world. Go to the ED “just to get checked out” and they’ll send you home.
  
• Gross malfeasance- There is a clinic that dumps on me that has a policy of not doing any definitive care for hand injuries. They got sued at some point. But they won’t be honest with the patients and just tell them they don’t do hands and send them to the ED initially which would be bad enough. No, they bring the patient into the clinic, do an x-ray, then tell the patient that they have to go to the ED after they bill them. Yup, that’s $175 to be told to go to the ED. And they knew from the get go that they weren’t going to do squat.
  
• Actual appropriate transfers (that have their own set of pitfalls)
  
  Actual conversation I had recently:
  PMD- “I’ve got a 68 yo M with HTN, DM who has crushing substernal chest pain. He feels weak and dizzy and is diaphoretic. I’m sending him to the ED.”
  Me- “We’ll save a bed and I’ll see him as soon as he gets here. Tell the medics to take him to room 5 and please send a copy of his old EKG. Did you give him an aspirin?”
  PMD- (long pause) “He left about 20 minutes ago. He’s driving himself over there.”
  Me- “Great. I’ll have security go check the parking lot for a dead guy in a parked car. He’s around 68 you said?”

Nursing homes are a separate issue. The main thing to know is that while there is a doctor who is technically in charge of nursing home patients his only duty is to round occasionally and collect the daily CMS billing (which is ridiculously low to be sure). If any acute issue develops (or chronic issues of course) those patients get sent to the ED. The unwritten rule is that 3 calls to the covering doc = go to the ED. Nursing homes also transfer patients to the ED if they are short nurses, tired, lazy or have patients with better paying insurance plans who they can put in the bed.

 

[EM2BE]

Also, you have to remember medicaid is probably included in the "insured" category...

 

[emtcsmith]

Actual conversation I had recently:
PMD- “I’ve got a 68 yo M with HTN, DM who has crushing substernal chest pain. He feels weak and dizzy and is diaphoretic. I’m sending him to the ED.”
Me- “We’ll save a bed and I’ll see him as soon as he gets here. Tell the medics to take him to room 5 and please send a copy of his old EKG. Did you give him an aspirin?”
PMD- (long pause) “He left about 20 minutes ago. He’s driving himself over there.”
Me- “Great. I’ll have security go check the parking lot for a dead guy in a parked car. He’s around 68 you said?”


But for all of these calls we get to the PMD's office there are twice as many "she had chest pain yeasterday, came to get check out today and now I want her to go to the ED"

Not to be topped by Nursing Home dumping on ED via 911 because they can't get a transport company in X time.

The uninsured, poor, sick and masses are going to come to the ED regardless so we need to do something to change the system.

 

[TerraMedicX]

Clinics dump an excessive number of their patients into the ED. Most of these are inappropriate. I see several issues that lead to dumps:

• Convenience- We get tons of dumps between 3 and 6 pm. Clinic is closing and this patient is still here so it’s off to the ED.
  
• Convenience- PMDs have to seed ~6 patients per hour to make up for the egregiously low reimbursement for an office visit. If whatever you need will take more than 5 minutes (you get 10 minutes total but that includes reading your chart, writing your scripts and writing in your chart too) it's off to the ED.
  
• Convenience- The patient needs some test and getting it cleared through the insurance company’s Byzantine pre-approval process will take time and effort. How to get it done fast and easy? Off to the ED with you!
  
• Convenience- The patient needs to be admitted but writing orders, checking with bed board and, again, negotiating the pre-approval process means time and effort. Go to the ED.
  
• Convenience- Minor lacerations, abscess I&D, IV hydration, LPs, splinting, enemas, etc. can be done in an outpatient clinic. But they are time consuming so it’s off to the ED.
  
• Convenience- No room on the schedule in clinic? Patients calling with new complaints? Just send them to the overflow clinic, um… I mean the ED.
  
• Liability- The PMD wants someone else to touch the patient before they go off into the world. Go to the ED “just to get checked out” and they’ll send you home.
  
• Gross malfeasance- There is a clinic that dumps on me that has a policy of not doing any definitive care for hand injuries. They got sued at some point. But they won’t be honest with the patients and just tell them they don’t do hands and send them to the ED initially which would be bad enough. No, they bring the patient into the clinic, do an x-ray, then tell the patient that they have to go to the ED after they bill them. Yup, that’s $175 to be told to go to the ED. And they knew from the get go that they weren’t going to do squat.
  
• Actual appropriate transfers (that have their own set of pitfalls)
  
  Actual conversation I had recently:
  PMD- “I’ve got a 68 yo M with HTN, DM who has crushing substernal chest pain. He feels weak and dizzy and is diaphoretic. I’m sending him to the ED.”
  Me- “We’ll save a bed and I’ll see him as soon as he gets here. Tell the medics to take him to room 5 and please send a copy of his old EKG. Did you give him an aspirin?”
  PMD- (long pause) “He left about 20 minutes ago. He’s driving himself over there.”
  Me- “Great. I’ll have security go check the parking lot for a dead guy in a parked car. He’s around 68 you said?”

Nursing homes are a separate issue. The main thing to know is that while there is a doctor who is technically in charge of nursing home patients his only duty is to round occasionally and collect the daily CMS billing (which is ridiculously low to be sure). If any acute issue develops (or chronic issues of course) those patients get sent to the ED. The unwritten rule is that 3 calls to the covering doc = go to the ED. Nursing homes also transfer patients to the ED if they are short nurses, tired, lazy or have patients with better paying insurance plans who they can put in the bed.

Absolutely 100% accurate from my experience!!

I'd also add that it seems that the general populace has NO concept of what an "Emergency" is anymore. On shift yesterday, I got called for a 21 y/o male who swallowed half of a tongue piercing that came out while eating, a 55 y/o female who had been vomiting for 2 hours and a 57 y/o female who had been experiencing some worsening pain from her gout for 4-5 days. Of course they all waiting until after 11pm to call! Do all these people need medical care...possibly. Do they need to goto the ED? Maybe the first guy, I suppose he could have damaged his esophagus. Do ANY of them need a 911 ambulance? NOPE! And that was a slow day!

Nate.

 

[Ypo.]

Actual conversation I had recently:
PMD- “I’ve got a 68 yo M with HTN, DM who has crushing substernal chest pain. He feels weak and dizzy and is diaphoretic. I’m sending him to the ED.”
Me- “We’ll save a bed and I’ll see him as soon as he gets here. Tell the medics to take him to room 5 and please send a copy of his old EKG. Did you give him an aspirin?”
PMD- (long pause) “He left about 20 minutes ago. He’s driving himself over there.”
Me- “Great. I’ll have security go check the parking lot for a dead guy in a parked car. He’s around 68 you said?”
[/LIST]

Interesting post. I hear a lot of specialties complain that ER physicians dump patients wherever they can but it sure sounds like the ER gets dumped on it's fair share as well.

Just curious; did the guy turn out to be having a MI?

 

[docB]

Interesting post. I hear a lot of specialties complain that ER physicians dump patients wherever they can but it sure sounds like the ER gets dumped on it's fair share as well.

The ER does dump a lot. Once you've done as much work up as you can and you're still not sure what's going on or the patient just looks like crap they get dumped on medicine. Elderly, demented and can't care for yourself? Sure you need a social worker more than a doctor but someone's gotta admit it. Most of the bitching happens in teaching hospitals. In the private world no one complains about taking a paying inpatient. Uninsured is another story.

Case in point I had a 70yoM with a hip fracture. Ortho wants to consult and have medicine admit (sheer laziness yes but it's the accepted culture where I am). The medicine call that night is just a crochety old guy who likes to fight about everything. He "refused" it. Now according to the bylaws I can just shove it down his throat but I was tired so I called another internist. He not only took it with no bitching he offered to take any similar patients in the future as well.

Just curious; did the guy turn out to be having a MI?

Guy never showed up. Don't know what happened. I do know that many patients sent by the PMD for some "emergent" issue show up hours later after they go home, eat, pack a bag, spoke a pack, play some poker, etc.

 

[GeneralVeers]

The ER does dump a lot. Once you've done as much work up as you can and you're still not sure what's going on or the patient just looks like crap they get dumped on medicine. Elderly, demented and can't care for yourself? Sure you need a social worker more than a doctor but someone's gotta admit it. Most of the bitching happens in teaching hospitals. In the private world no one complains about taking a paying inpatient. Uninsured is another story.

Case in point I had a 70yoM with a hip fracture. Ortho wants to consult and have medicine admit (sheer laziness yes but it's the accepted culture where I am). The medicine call that night is just a crochety old guy who likes to fight about everything. He "refused" it. Now according to the bylaws I can just shove it down his throat but I was tired so I called another internist. He not only took it with no bitching he offered to take any similar patients in the future as well.
QUOTE]

The hospitalists and specialists who see or admit a patient without complaining are the ones who get the most business from me. Specialists need to learn that E.D. physicians are a good portion of their income, and it will benefit them in the long run to help us out without complaining.

Last night I had to admit a liver patient with hepatic encephalopathy, hepatorenal syndrome, and ITP. He had insurance. The on-call hospitalist is a lazy *** who doesn't return his calls on time, and give me grief when he does. I went out of my way to have a different hospitalist admit the patient just so I wouldn't have to talk to the ***.

 

[crewmaster1]

A great opening question I've been asking my patients today is "what is your emergency" or "what emergency brings you here today?" It is quite entertaining to see the look on their face and how they often feel sheepish trying to then give their chief complaint about some BS minor medical complaint.

 

[GeneralVeers]

A great opening question I've been asking my patients today is "what is your emergency" or "what emergency brings you here today?" It is quite entertaining to see the look on their face and how they often feel sheepish trying to then give their chief complaint about some BS minor medical complaint.

I've tried that, and most patients don't even blink, as they start describing their little toe pain X 5 years as an emergency.

 

[DocER]

i've tried that line, too - the "what is your emergency today?" it never ceases to amaze me what people consider to be an emergency. i always wish i could bring those ignorant people into the resus room when i'm running a code or when i have a sick child or someone's having an MI. however, i still don't think they'd get it.

i once had a patient yell at me for leaving the room to deal with a severe anaphylactic reaction. she was there for an ultrasound report. she couldn't understand that when the nurse paged me overhead to resus STAT, that there maybe existed a real "emergency" other than her getting her u/s report.

i agree with everyone, though, about the issues crowding the ER. the other thing is not enough beds, not enough staff...

 

[Kubed]

A great opening question I've been asking my patients today is "what is your emergency" or "what emergency brings you here today?" It is quite entertaining to see the look on their face and how they often feel sheepish trying to then give their chief complaint about some BS minor medical complaint.

Lately I've been enjoying asking "so what changed that made you think "that's it! I've got to go to the emergency department right now!""

 

[GeneralVeers]

Lately I've been enjoying asking "so what changed that made you think "that's it! I've got to go to the emergency department right now!""

Usually they say: "I just want to find out why I'm having chronic pain"

At which point I respond: "My job is to rule out things that will kill you. I probably will not have an answer as to why you have chronic pain."

At which point the patient gives me a blank uncomprehending stare.

 

[Faebinder]

There is no way around this mess and still keep the stupid EMTALA alive.

Whatever solution you think, it will be trumped sooner or later by EMTALA.

Collect copays upfront? --> Dont have money but you EMTALA protects them.

Charge insurance copay? --> Insurance wont pay.

Refuse to see patient? --> EMTALA makes you see them.

 

[GeneralVeers]

There is no way around this mess and still keep the stupid EMTALA alive.

Whatever solution you think, it will be trumped sooner or later by EMTALA.

Collect copays upfront? --> Dont have money but you EMTALA protects them.

Charge insurance copay? --> Insurance wont pay.

Refuse to see patient? --> EMTALA makes you see them.

The biggest problem I have with EMTALA is the "medical screening exam" which usually has to be done by a doctor. If I have to go to the waiting room and do a medical screening exam, it would be just as fast to see, treat, and discharge the patient.

EMTALA needs to be altered such that visits which are clearly level 4 and 5 can be screened by the triage nurse. If you have a cold and runny nose, with normal vital signs and no co-morbidities, the triage nurse can easily weed you out.

 

[docB]

The biggest problem I have with EMTALA is the "medical screening exam" which usually has to be done by a doctor. If I have to go to the waiting room and do a medical screening exam, it would be just as fast to see, treat, and discharge the patient.

EMTALA needs to be altered such that visits which are clearly level 4 and 5 can be screened by the triage nurse. If you have a cold and runny nose, with normal vital signs and no co-morbidities, the triage nurse can easily weed you out.

Interestingly EMTALA does not specify who has to do the MSE. I believe the language calls for "an appropriate healthcare provider" or something equally vague. It's usually an institutional policy that it has to be a doc because most EPs are contractors of the hospital. Thus if we certify a patient as non-emergent and we're wrong it's on us and not on the institution.

 

[Hawkeye Kid]

2 cases from last night that speak to non-emergent conditions and consultant resistance:

1. quad sent from ECF because they "are unable to provide for her needs." she was d/c'd by our hospitalist service 10d ago, and apparently there was an agreement between them and the ECF that she was going on a "trial basis" and that they could send her back if things didn't fly. the hospitalists don't want her because she has no acute issues, and it's friday night, so good luck placing her from the ED (our case managers are actually very aggressive/good about this when possible). FP won't take her b/c she's a hospitalist pt. so the attending spends about an hour total on the phone trying to dispo the lady. the hospitalist recommended the obs unit (an extension of the ED) to try to place her today--and if that doesn't happen (and they agree it won't) then they'll admit her. brilliant.

2. lady comes in with progressive R sided weakness and vision changes since DECEMBER. she has a hx of CVA and can't really tell me what's different except that she's getting worse. she can't even pin down what is residual from her old CVA and what's new(ish). she has seen her primary about this and has an appt with neuro next month. only came to the ED last night b/c her son was coming in for an injury. she says she hasn't had a head CT since this all started getting worse, and i didn't want to miss something just b/c i was annoyed, so i scanned her. rads calls--subacute (less than a week) occipital stroke. call neuro--she needs to be admitted, but not to me b/c it's not acute. call the hospitalist--they think she needs to go to neuro but reluctantly agree to take her after some venting about the system. again, brilliant.

do any of your hospitals have policies saying who admits what? like, if the admission diagnosis is CVA, neuro admits, renal failure goes to nephro, etc? it seems like more and more those things go to medicine with consults and it just doesn't make much sense--not to mention that it causes their services to be more stressed than they already are. any thoughts?

 

[Febrifuge]

I thought there were hospitals where the staff EPs have admitting privileges to every service in the building... in other words they ask Neuro to take a patient out of courtesy, but if need be they can tell Neuro that a new patient will be coming in tonight and would they mind coming down to have a look at their new patient now please kthxbye click.

Or have I merely witnessed a teaching hospital thing and/or a place where these issues are not such a factor?

 

[enfuegoEP]

A great opening question I've been asking my patients today is "what is your emergency" or "what emergency brings you here today?" It is quite entertaining to see the look on their face and how they often feel sheepish trying to then give their chief complaint about some BS minor medical complaint.

One thing that irks the sh&^ out of me is when girls come to the ED for a pregnancy test. Do any of you get that? 20 bucks at Wallgreens can save you a 600.00 ED bill that the hospital will sick collection agencies on you when you don't pay...To find out if you're pregnant... when you HAVEN'T HAD YOUR PERIOD IN 3 MONTHS. I've seen a number of these. Is this a local phenom or do any of you see the same thing.

 

[DocER]

One thing that irks the sh&^ out of me is when girls come to the ED for a pregnancy test. Do any of you get that? 20 bucks at Wallgreens can save you a 600.00 ED bill that the hospital will sick collection agencies on you when you don't pay...To find out if you're pregnant... when you HAVEN'T HAD YOUR PERIOD IN 3 MONTHS. I've seen a number of these. Is this a local phenom or do any of you see the same thing.

WOW! i work in canada and thought that only happened here... craziness!

 

[GeneralVeers]

WOW! i work in canada and thought that only happened here... craziness!

Except in Canada you don't get the bill for $600, rather this expense is passed on to all of the taxpayers.

 

[EM2BE]

One thing that irks the sh&^ out of me is when girls come to the ED for a pregnancy test. Do any of you get that? 20 bucks at Wallgreens can save you a 600.00 ED bill that the hospital will sick collection agencies on you when you don't pay...To find out if you're pregnant... when you HAVEN'T HAD YOUR PERIOD IN 3 MONTHS. I've seen a number of these. Is this a local phenom or do any of you see the same thing.

Definitely seen this one. Except the girl was puking for a week or so, mom was worried, girl (in high school) didn't tell her mom about her missed periods until the dr/nurse asked her. Then the mom said, oh yep, she's pregnant before the results even got back. Girl got rehydrated and some info about prenatal info and left. But they were of course out-of-towners too, so they probably made the right decision in the end (none of their own doctors around for a few weeks).

 

[enfuegoEP]

Except in Canada you don't get the bill for $600, rather this expense is passed on to all of the taxpayers.

That's the rub...GV is right. We have a public funded health trust that donates about 55 million a year to care for the uninsured. After they find out the test was positive, they want to see an ultrasound. I know a trauma surgeon who is paying 30K a year in property tax...If I told him these stories he'd go postal.

 

[DocER]

Except in Canada you don't get the bill for $600, rather this expense is passed on to all of the taxpayers.

very true. the perception in canada is that if the patients had to pay for these silly reasons to come to ER, they wouldn't come. obviously, that is not quite true.

 

[Jeff698]

very true. the perception in canada is that if the patients had to pay for these silly reasons to come to ER, they wouldn't come. obviously, that is not quite true.

Please, don't use us as an example of why this isn't true. These women (and yes, we have plenty of them as well) aren't going to pay their bill. Screw the collectors and add 'em to the list, they say.

BTW, I also have them come in wanting an US of the baby. Word on the street is if you say you're belly hurts or you have vag bleeding, you get an US for free! Who could say no to that?

re turf admit battles. Just this morning... 60ish woman with umpteen nasty, relatively rare comorbities with femoral neck fracture. Ortho says she should go to medicine. Medicine says no way in hell. Ortho digs in heals and says no. I say I'm not sending her home. Now it's a three way standoff and I'm left holding the bag. Ultimately, medicine reviews the EMR and admits with ortho consulting.

If anyone asks what one of the downsides to EM is.... here's their answer.

Take care,
Jeff

 

[enfuegoEP]

Word on the street is if you say you're belly hurts or you have vag bleeding, you get an US for free! Who could say no to that?
Take care,
Jeff

Looks like the word reached our streets. They claim abd pain but show absolutely no signs or symptoms. Get the US and smile and always ask "Is it a boy or girl?"

 

[GeneralVeers]

We've made the decision as a society that we will pay for everything for people who don't necessarily deserve anything. Given that we've made that collective decision (and have acted upon it through policy since the 1930's) there's little we can do to change the situation. Dumb, ignorant, or just lazy people will always abuse the system. There's no way to curb this without altering the entitlement society we've created.

 

[EM2BE]

Makes me think about the "free clinics." They offer services only if you provide proof of income (your last pay stub) and offer prices at a sliding fee according to their income. I wonder if they could do something similar in the ED with those that come in with silly complaints. Ask them for their last pay stub or proof of disability. Neither = no service if not an actual emergency.

 

[GeneralVeers]

Makes me think about the "free clinics." They offer services only if you provide proof of income (your last pay stub) and offer prices at a sliding fee according to their income. I wonder if they could do something similar in the ED with those that come in with silly complaints. Ask them for their last pay stub or proof of disability. Neither = no service if not an actual emergency.

Again, it comes down to who will decide what is an "emergency". Do you want to be the one who's license is on the line if you turn away something that looks benign, but the patient has a bad outcome? The safest policy is to see everyone for free, as impossible as it sounds.

 

[fab4fan]

Lately I've been enjoying asking "so what changed that made you think "that's it! I've got to go to the emergency department right now!""

I asked someone that one time when she presented in triage with a c/o abd pain x 2 years; she'd already been worked up in the past by a gi doc and knew what her problem was and what she needed to do. She said she thought she ought to get it checked out just in case something had changed.

People are shameless.

 

[Apollyon]

Again, it comes down to who will decide what is an "emergency". Do you want to be the one who's license is on the line if you turn away something that looks benign, but the patient has a bad outcome? The safest policy is to see everyone for free, as impossible as it sounds.

We do it - an exam to rule out any life threats, then send the business office people in to collect a nominal fee. This is for frequent flyers, and a specified list of conditions (like dental pain and requesting pain medications). They pony up, and they get the complete workup. And these layabouts won't even pay the tiny amount asked. I'm not worried about my license.

 

[Jeff698]

Looks like the word reached our streets. They claim abd pain but show absolutely no signs or symptoms. Get the US and smile and always ask "Is it a boy or girl?"

"Hmmm, hard to say but I think it'll be another freeloading, system-abusing, symptom-faking, vicodin-seeking troll....just like it's mommy"


Or something like that.

Take care,
Jeff

 

[Seaglass]

Except in Canada you don't get the bill for $600, rather this expense is passed on to all of the taxpayers.

In the US it is also passed on to the taxpayers - in the form of an unpaid visit or medicaid.

 

[EM2BE]

Along these lines:

Professor says physicians should eliminate health insurance "Mafia."

In an op-ed published in the Wall Street Journal (4/14, A15), Jonathan Kellerman, Ph.D., author and clinical professor of pediatrics and psychology at the University of South Carolina's Keck School of Medicine, writes, "Most discussions about the rising cost of healthcare emphasize the need to get more people insured." Yet, he said, "perhaps the solution to much of what currently plagues us in healthcare -- rising costs and bureaucracy, diminishing levels of service -- rests on a radically different approach: fewer people insured." Kellerman suggests that the cost of healthcare is increased by having an insurance "Mafia," or middleman, between physicians and patients. The solution, Kellerman says, is for physicians and patients to deal with each other directly. He concludes, "Physicians and other providers need to liberate themselves from the Faustian bargain they've cut with the Mephistophelian suits who now run their professional lives. Because many doctors are loath to talk about money, they allowed themselves to perpetuate the fantasy that 'insurance is paying.' It isn't."

 

[jbar]

Cutting out the insurance would just being going back to a fee for service deal where doctors were paid every time that they do something. If people just paid their doctor, what would happen if they had a stroke? Would they suddenly owe the doctor/hospial $200,000 on their own with no other source of funding?
The whole point of insurance is to spread the risk of an expensive illness/accident amongst a large pool. You inherently need some sort of administration to determine how much everyone pays and how much you can get out. The main problem is that health insurance is a for profit entity that seeks to limit what it pays out to maximize profit. Ideally money in would =money out, with a small percentage to cover costs. But that's not what's happening.

 

[docB]

Along these lines:

He concludes, "Physicians and other providers need to liberate themselves from the Faustian bargain they've cut with the Mephistophelian suits who now run their professional lives.

I have trouble with any argument that uses the adjectives "Faustian" and "Mephistophelian" in the same sentence.

 

[novastorm]

Yes and No. It depends largely on location and the makeup of the population being served, the amount of resources the community is willing to put into the health care system etc. In one case I can say YES in others its really not that big of a deal.

 

[enfuegoEP]

I have trouble with any argument that uses the adjectives "Faustian" and "Mephistophelian" in the same sentence.

Me too...especially since I don't know what either one means.

 

[GeneralVeers]

Me too...especially since I don't know what either one means.

Health insurance = The Devil

 

[Apollyon]

Me too...especially since I don't know what either one means.

Faust sold his soul to the devil. "Mephistophelian" is a snooty way of saying "devil-like", as Mephistopheles is another name for Satan.

 

[deleted109597]

Faust sold his soul to the devil. "Mephistophelian" is a snooty way of saying "devil-like", as Mephistopheles is another name for Satan.

Jesus. At least somebody watched Tombstone (the greatest movie ever made). Actually, he probably read the book/watched an actual play. Either way.
For the unwashed...

 

[enfuegoEP]

Jesus. At least somebody watched Tombstone (the greatest movie ever made).

Easy big fella...don't start a flame war by saying tombstone is the greatest movie ever made. I can think of a few that rank above tombstone.

Braveheart

Pulp Fiction

The Godfather

 

[enfuegoEP]

Health insurance = The Devil

I thought foosball and Vicky Valencourt=The Devil????

 

[deleted109597]

Easy big fella...don't start a flame war by saying tombstone is the greatest movie ever made. I can think of a few that rank above tombstone.

Braveheart

Pulp Fiction

The Godfather

I dunno, Pulp Fiction, although good, ranks up there with The Big Lebowski. However, from the sheer volume of stuff that makes it into my daily lingo, Tombstone will always win.
Huckleberry
Frederich "****ing" Chopin
I'm rolling
He's over there, walking on water
Actually, just the character of Doc Holliday might be the single greatest character ever written. Val Kilmer did a great job.

 

[Apollyon]

Jesus. At least somebody watched Tombstone (the greatest movie ever made). Actually, he probably read the book/watched an actual play. Either way.[/IMG]

One day as a resident, I said something that I don't recall, and one of the nurses asked if I got it from The DaVinci Code. I said, no, I did it the hard way, through my classical education.

This is the second such instance. I wish it were only the Cliff's Notes version, but I'm well-acquainted (as you are) with Cliff's older brother - the big, friggin', 1200 page book that weighs 4 pounds and has more footnotes than lines of text.

Although I have, more times than I can count, seen Tombstone.

 

[Farmer Jane]

Recently a nursing home patient was brought in my ambulance for difficulty breathing. Once the sputum-clog was suctioned out of her trach she was fine. 🙄 The NH refused to take her back because they didn't have enough staff. 😕

 

[enfuegoEP]

Not sure what's going on with the the randomness above me..but here's a memorable quote..

Maude Lebowski: What do you do for recreation?
The Dude: Oh, the usual. I bowl. Drive around. The occasional acid flashback.

 

[Febrifuge]

Every day we have physical exam lab, I can't help thinking

"He's a good man. And thorough."

It's funny, how having a liberal arts education makes a guy a freak and/or a genius in medical training. I've decided to enjoy it.

 

[Farmer Jane]

Randomness? Much of the thread discussed inappropriate use of ER resources.

Anyway, my favorite bit was the marmot in the bathtub.