Medicare Patients and "Observation"

[Perrotfish]

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OMG, thiiiiiss...... again and again and again.

Had a patient straight-up tell me last shift: "Don't make me observation, I need to be full inpatient, because then they won't pay for it."

Medicine costs (f)ucking money, people.

The problem is that in the ER medicine (and to a lesser extent inpatient hospital medicine) bills for exponentially more than it costs. Get the wrong care in the ER and the hospital will use it as an excuse to take everything you own. Its legalized robbery.

One of the problems with too much government intervention in medical care is that, since hospitals primarily deal with insurance at this point (government or otherwise) they have no sane dynamic left for patients who actually need to pay for their care with cash. ERs make up a completely fake, completely obscene number for the cost of care of a patient (you sat on a bed for 18 hours, were seen by a physician for thirty minutes, and recieved three tylenol: $25,000) which they then send off to either the patient's insurance company or, if he has no insurance, the patient himself. Obviously the insurance companies view this as the first offer in a negotation, and then reimburse for their actual rate (How about $750?) which bears some relationship to the actual cost of care and almost no relationship to the hospitals opening bid. However if you're cash pay the hospital treats their first, completely insane offer as though it were the actual cost of your bill, and they set then they set the dogs of their collection agency on you if/when you refuse to pay, because they argue that when you accepted the care you accepted the responsibility to pay for it (even though they refused to give you the bill until you had already accepted the care) and because they know that you don't have the resources to fight back.

I know that you guys think that no one in the ER pays for their care. The truth is, though, that there really are a lot of people who walk through the door who aren't homeless derilects, who really do have some savings and property to lose. And when they come in, the hospital smells blood in the water. Someone here posted about a patient that was still paying down a nearly three THOUSAND dollar bill from their last Obs visit. Do you have any idea what kind a blow a three thousand dollar loss is to an average person? For half of Americans that would litteraly destroy their savings and leave them destitute. And are we honestly going to pretend that there was any cost associated with that patient's care (who was on Obs) that required it to cost twenty times what an outpatient Urgent care visit costs? A lot of people who go to an ER genuinely don't know that they're walking into a billing trap where they can lose their savings and their home in exchange for a quick once over evaluation and 2 dollars worth of Motrin. And for those poor souls who are sick enough to go to the ER knowing the risks that they face, can you really blame them for trying to navigate the minefield and telling you 'NO!' when you send them to the unit their insurance won't pay for? Would you have said yes?

 

[RustedFox]

The problem is that in the ER medicine (and to a lesser extent inpatient hospital medicine) bills for exponentially more than it costs. Get the wrong care in the ER and the hospital will use it as an excuse to take everything you own. Its legalized robbery.

One of the problems with too much government intervention in medical care is that, since hospitals primarily deal with insurance at this point (government or otherwise) they have no sane dynamic left for patients who actually need to pay for their care with cash. ERs make up a completely fake, completely obscene number for the cost of care of a patient (you sat on a bed for 18 hours, were seen by a physician for thirty minutes, and recieved three tylenol: $25,000) which they then send off to either the patient's insurance company or, if he has no insurance, the patient himself. Obviously the insurance companies view this as the first offer in a negotation, and then reimburse for their actual rate (How about $750?) which bears some relationship to the actual cost of care and almost no relationship to the hospitals opening bid. However if you're cash pay the hospital treats their first, completely insane offer as though it were the actual cost of your bill, and they set then they set the dogs of their collection agency on you if/when you refuse to pay, because they argue that when you accepted the care you accepted the responsibility to pay for it (even though they refused to give you the bill until you had already accepted the care) and because they know that you don't have the resources to fight back.

I know that you guys think that no one in the ER pays for their care. The truth is, though, that there really are a lot of people who walk through the door who aren't homeless derilects, who really do have some savings and property to lose. And when they come in, the hospital smells blood in the water. Someone here posted about a patient that was still paying down a nearly three THOUSAND dollar bill from their last Obs visit. Do you have any idea what kind a blow a three thousand dollar loss is to an average person? For half of Americans that would litteraly destroy their savings and leave them destitute. And are we honestly going to pretend that there was any cost associated with that patient's care (who was on Obs) that required it to cost twenty times what an outpatient Urgent care visit costs? A lot of people who go to an ER genuinely don't know that they're walking into a billing trap where they can lose their savings and their home in exchange for a quick once over evaluation and 2 dollars worth of Motrin. And for those poor souls who are sick enough to go to the ER knowing the risks that they face, can you really blame them for trying to navigate the minefield and telling you 'NO!' when you send them to the unit their insurance won't pay for?

There's a lot of truth to what you say; but the fact remains: Medicine costs money. A lot of it. The hospital is trying to recover its losses by being forced at gunpoint (legalized robbery) to treat those who abuse the system with no guarantee of getting paid. If people were more circumspect about how they used the ER (no, this is not the place for your dental pain, well-baby check, or family that all has the sniffles), then we'd see a lot less of these outrageous billing practices. Until all the players involved (that is, insurance companies, the federal government, the hospitals... and gasp... the patients themselves) come to the realization that "wait, this is completely unrealistic and unsustainable to be spending this amount of money for services", then its a free-for-all.

Its lunacy that I see so many giant, obese, diabetic, smoking, noncontributory members of society come thru the ED on a daily basis... without ever a thought as to how much their care ACTUALLY costs. Oddly enough, a lot of them have had several episodes of cardiac cath/stenting, or have their CABG scar. They continue to be in poor health, largely because of their own irresponsible life choices. We have to think about this, as 'payors'. If you're already on the take for whatever reason... sorry, you can't force me to be a victim of "legalized robbery" in the form of increased taxes such that you get your CABG, and then hold me at gunpoint on the other end when I *have* to treat your chest pain/SOB, etc.

 

[Rendar5]

This is taken to an extreme by the hospital where I train.

To the point where admissions are blocked first by the "Resource Utilization nurse" then again by the medicine resident.

I'm concerned that isn't great for my training, as now my decision to admit or discharge is based on a government selected set of criteria without any evidence, and any effort to "fight" for a legit medico-legal admit that doesn't meet criteria ends up getting reviewed by QI, and results in multiple e-mails and meetings. Patients get stuck in a limbo of being too sick too go home, and too well to be admitted.

Other day I was told I had to discharge a pt with HR 140 and a IJ central line getting Vanc Zosyn for her what turned out to be MRSA pneumonia because she didn't "meet criteria" while she was in the ED.

"Just pull her central line and send her home" - Utilization nurse

Also the first time the "I just want to do whats right for the patient" line has been countered with "I don't care, I want what is cheapest for the hospital" . How do you respond to that!!!

You ask them to go into the room with you to explain that to the patient. If they're still persistent, when you walk into the room with them, tell the patient that as their doctor you recommend that they be admitted because they may die from their disease if they go home, then introduce the utilization nurse by her full name (spell it out for them) and ask her to explain that to the patient.

 

[Rendar5]

The problem is that in the ER medicine (and to a lesser extent inpatient hospital medicine) bills for exponentially more than it costs. Get the wrong care in the ER and the hospital will use it as an excuse to take everything you own. Its legalized robbery.

One of the problems with too much government intervention in medical care is that, since hospitals primarily deal with insurance at this point (government or otherwise) they have no sane dynamic left for patients who actually need to pay for their care with cash. ERs make up a completely fake, completely obscene number for the cost of care of a patient (you sat on a bed for 18 hours, were seen by a physician for thirty minutes, and recieved three tylenol: $25,000) which they then send off to either the patient's insurance company or, if he has no insurance, the patient himself. Obviously the insurance companies view this as the first offer in a negotation, and then reimburse for their actual rate (How about $750?) which bears some relationship to the actual cost of care and almost no relationship to the hospitals opening bid. However if you're cash pay the hospital treats their first, completely insane offer as though it were the actual cost of your bill, and they set then they set the dogs of their collection agency on you if/when you refuse to pay, because they argue that when you accepted the care you accepted the responsibility to pay for it (even though they refused to give you the bill until you had already accepted the care) and because they know that you don't have the resources to fight back.

I know that you guys think that no one in the ER pays for their care. The truth is, though, that there really are a lot of people who walk through the door who aren't homeless derilects, who really do have some savings and property to lose. And when they come in, the hospital smells blood in the water. Someone here posted about a patient that was still paying down a nearly three THOUSAND dollar bill from their last Obs visit. Do you have any idea what kind a blow a three thousand dollar loss is to an average person? For half of Americans that would litteraly destroy their savings and leave them destitute. And are we honestly going to pretend that there was any cost associated with that patient's care (who was on Obs) that required it to cost twenty times what an outpatient Urgent care visit costs? A lot of people who go to an ER genuinely don't know that they're walking into a billing trap where they can lose their savings and their home in exchange for a quick once over evaluation and 2 dollars worth of Motrin. And for those poor souls who are sick enough to go to the ER knowing the risks that they face, can you really blame them for trying to navigate the minefield and telling you 'NO!' when you send them to the unit their insurance won't pay for? Would you have said yes?

I generally tell patients that any bill they get from the ER for their care should be discussed with the billing dept and can likely be negotiated. That said, I pay over $3000/year for medical insurance. A one time $3000 bill (an obs admission or a very full ED visit +multi-imaging workup that is paid over the course of a year or two is not unreasonable, it's what people with insurance pay year after year, even if it's as part of their benefits. Maybe if society were a little-less sue-happy, I could be a little less test-happy and save them some money in the long run

 

[Perrotfish]

There's a lot of truth to what you say; but the fact remains: Medicine costs money. A lot of it. The hospital is trying to recover its losses by being forced at gunpoint (legalized robbery) to treat those who abuse the system with no guarantee of getting paid. If people were more circumspect about how they used the ER (no, this is not the place for your dental pain, well-baby check, or family that all has the sniffles), then we'd see a lot less of these outrageous billing practices. Until all the players involved (that is, insurance companies, the federal government, the hospitals... and gasp... the patients themselves) come to the realization that "wait, this is completely unrealistic and unsustainable to be spending this amount of money for services", then its a free-for-all.

Its lunacy that I see so many giant, obese, diabetic, smoking, noncontributory members of society come thru the ED on a daily basis... without ever a thought as to how much their care ACTUALLY costs. Oddly enough, a lot of them have had several episodes of cardiac cath/stenting, or have their CABG scar. They continue to be in poor health, largely because of their own irresponsible life choices. We have to think about this, as 'payors'. If you're already on the take for whatever reason... sorry, you can't force me to be a victim of "legalized robbery" in the form of increased taxes such that you get your CABG, and then hold me at gunpoint on the other end when I *have* to treat your chest pain/SOB, etc.

1) I don't believe that patients who abuse the ER and abusive billing practices are related to eachother. Hospitals don't have insane billing processes as some sort of a roundabout way of compensating for EMTALA patitents, they do it because they can get away with it. If the non-pays disappeared tomorrow they would still have their collection agencies at the ready, just like the irresponsible patients would keep coming if the collection agencies disappeared.

2) I think you might be surprised how many of the 'giant, obese, diabetic, smoking' patients are or were the people that make society run. While I will admit that there are more than a few crack addicts with 18 children passing through inner city EDs, a lot of the really fat, miserable patients I encountered were former shipbuilders, dockworkers, and other blue collar type men/women. Also FWIW I think that being giant, obese, and diabetic is not primarily a life choice. I highly recommend Taubes's "why we get fat" for an alternate theory on why our population is getting larger that doesn't put all the emphasis on irresponsibility. I'm not necessarily disagreeing with you that you about the obscene legal risks of treating the uninsured you have to treat, but I think you're assuming way too much about their drive and motivation as human beings.

A tangential question: why do you do what you do? It seems like you really don't like at least most of your patients. And you think the hospital system is oppresive, money driven, and miserable. Which honestly is what I thought of the adult ED, but that was why I didn't pursue a career in the adult ED. If you hate your patients and you hate the hospital, have you ever considered a different field? I don't mean to be rude, your posts just seem really bitter and I'm curious what motivates you to keep showing up to work.

 

[Perrotfish]

I generally tell patients that any bill they get from the ER for their care should be discussed with the billing dept and can likely be negotiated.

Having been on the other side of it: no it can't. I mean, I am sure they will negotiate if you say "I'm flat broke and behind on all my credit cards' and they know that there is nothing to be gained by chasing you, but if you have assets there is no negotation. You pay or they send the collection agency after you.

That said, I pay over $3000/year for medical insurance. A one time $3000 bill (an obs admission or a very full ED visit +multi-imaging workup that is paid over the course of a year or two is not unreasonable, it's what people with insurance pay year after year, even if it's as part of their benefits

The thing, though, is that this isn't what most people pay for insurance. Rather the $3,000 price tag is why most people don't have insurance (in their benifits or otherwise), or they have some crappy $500/year catastrophic care policy that only kicks in when the cost of care goes over 20K. It IS an unreasonable cost for almost anyone going into the ED. In any event its always unreasonble to send someone a bill for an amount which they did not agree upon before services were rendered, and no other business is allowed to operate that way.

 

[deleted109597]

It IS an unreasonable cost for almost anyone going into the ED. In any event its always unreasonble to send someone a bill for an amount which they did not agree upon before services were rendered, and no other business is allowed to operate that way.

It is unreasonable for anyone to be able to walk in and be seen without making sure of their ability to pay as well. You can't go to the repairman with a bad transmission and force them to fix it without being able to pay for it. One difference is, the repairman has to give you an estimate before work begins. If we gave estimates, suddenly people would be refusing tests due to cost, and with the liability nightmare in this country, the lawsuits would likely go up.

I wish we could post a cost list in the ED, clinics, and hospitals. I think making the system more transparent would be ideal. I just don't see it happening.

As far as "crappy" insurance policies or whatever, I didn't force them to buy that insurance. They were supposed to read the deductibles and out of network costs of the policy. The fact that California has allowed insurance companies to decline payments to EDs for out of network, and then the hospitals are not allowed to balance bill to make up the deficit is even more ludicrous. EMTALA really is to blame for a significant portion of this problem.

 

[docB]

No way this actually happened.

It's happened to me. It wasn't the UR nurse, it was the HMO doctor. Had to put in an IJ on a drug seeking gastroparesis frequent flyer. She barfed her K down to 2.3. Got told to give some K, pull the line and kick her out. I had to give some K and then recheck the BMP to show it wasn't coming up enough to get the admit.

This is taken to an extreme by the hospital where I train.

To the point where admissions are blocked first by the "Resource Utilization nurse" then again by the medicine resident.

I'm concerned that isn't great for my training, as now my decision to admit or discharge is based on a government selected set of criteria without any evidence, and any effort to "fight" for a legit medico-legal admit that doesn't meet criteria ends up getting reviewed by QI, and results in multiple e-mails and meetings. Patients get stuck in a limbo of being too sick too go home, and too well to be admitted.

Other day I was told I had to discharge a pt with HR 140 and a IJ central line getting Vanc Zosyn for her what turned out to be MRSA pneumonia because she didn't "meet criteria" while she was in the ED.

"Just pull her central line and send her home" - Utilization nurse

Also the first time the "I just want to do whats right for the patient" line has been countered with "I don't care, I want what is cheapest for the hospital" . How do you respond to that!!!

I would ask that person to spell her name for the medical record and explain that I was going to document that I had been told to d/c the patient by her and against my judgement. It won't protect you legally and it would cause a fight with admin but it would likely get her to back off for the moment.

 

[RustedFox]

1) I don't believe that patients who abuse the ER and abusive billing practices are related to eachother. Hospitals don't have insane billing processes as some sort of a roundabout way of compensating for EMTALA patitents, they do it because they can get away with it.

Wow. Sorry man, but you're dead-wrong here.

2) I think you might be surprised how many of the 'giant, obese, diabetic, smoking' patients are or were the people that make society run. While I will admit that there are more than a few crack addicts with 18 children passing through inner city EDs, a lot of the really fat, miserable patients I encountered were former shipbuilders, dockworkers, and other blue collar type men/women.

Not everyone is a worthless slug, I confess; but my point remains: I'm outraged that anyone wants to make the taxpayers pay, through legalized robbery, for the poor choices and decisions of anyone else. You can have anything you want; as long as you can pay for it. We wouldn't have half of the problems that we currently do (in both medicine and society), if PERSONAL RESPONSIBILITY was paramount. Want to be a career three-pack-a day girl ? Sure, g'head... but have realistic expectations about how you're going to die; young, and suffocating.

Also FWIW I think that being giant, obese, and diabetic is not primarily a life choice. I highly recommend Taubes's "why we get fat" for an alternate theory on why our population is getting larger that doesn't put all the emphasis on irresponsibility. I'm not necessarily disagreeing with you that you about the obscene legal risks of treating the uninsured you have to treat, but I think you're assuming way too much about their drive and motivation as human beings.

You clearly don't work in an ED where you see the same *******es come thru on a weekly basis for the exact same things. Can't breathe, Ms. Johnson? Again? Is that a fresh 'hard pack' of Marboros in your jacket pocket? Hmm. Sugar of 800+ again, Mr. Jones? Don't "feel like" taking your Metformin and other drugs? Can't afford them? They're four dollars at the grocery store, yet you choose to spend those four dollars on the fast food in the greasy bag that you came in with.

Everything is a matter of choice. And every choice has consequences. I'll come back to that later.

A tangential question: why do you do what you do? It seems like you really don't like at least most of your patients. And you think the hospital system is oppresive, money driven, and miserable. Which honestly is what I thought of the adult ED, but that was why I didn't pursue a career in the adult ED. If you hate your patients and you hate the hospital, have you ever considered a different field? I don't mean to be rude, your posts just seem really bitter and I'm curious what motivates you to keep showing up to work.

If you met me in person (any of you guys on here who know me in real-life, g'head and chime-in), you'd find that I'm actually one of the more hypersocial, affable, ebullient individuals on this planet. No joke.

I chose EM because I would rather not do anything else in medicine. I lack the patience for IM/FM. I hated surgery/OBGYN. Subspecialty fields would have required me to stay in a fellowship until my late 30s, at which point I'd have to say - "Wow, what have I done with my twenties and thirties? I thought I'd be enjoying life more and working less."

My saltiness is a shared one amongst many people, not just in my field, not just in medicine. I'm "Going Galt", as it is commonly said. Its the "entitlement society" that exists here in the US that is completely unsustainable, and has put the medicolegal gunbarrel to our heads. See any of Birdstrike's or Veers' posts for a lengthier discussion on Libertarianism. Everything is a choice, and every choice has consequences that you had better be prepared to take responsibility for. If you want to live to be 80+ and healthy... then CHOOSE to. I am hypervigilant and hyperscrutinizing about everything that I put into my body. Personal responsibility. As far as why we get fat ? Calories in, calories out, man. Nobody chooses your behavior but you. Sure, endocrine glands go wacky, and we can try and fix these; but this is a small fraction of the cases at large. The vaaaast majority of obesity/DM/HTN/CAD in the United States is due to.... poor choices. People choose a lifetime of McDonalds, Marlboros, and daytime TV when they NEED to choose a smaller, healthier diet, and a pair of running shoes.

 

[shopsteward]

As far as why we get fat ? Calories in, calories out, man. Nobody chooses your behavior but you. Sure, endocrine glands go wacky, and we can try and fix these; but this is a small fraction of the cases at large. The vaaaast majority of obesity/DM/HTN/CAD in the United States is due to.... poor choices. People choose a lifetime of McDonalds, Marlboros, and daytime TV when they NEED to choose a smaller, healthier diet, and a pair of running shoes.

One of the side effects of capitalism is that not everyone has the same degree of choice. Money is only one form of rationing, and there are many other forms of poverty than the strictly monetary. If you are poor in education, or location, or upbringing, or friends/relatives - and often people who are poor in money are also poor in these other things, through no fault of their own - then the choices available to you will be limited. Some people break out of these situations (usually those people who have at least one advantage available to them which offsets the disadvantages), but most don't, for multiple and forgiveable reasons.

Plus, society is organised to drive people to unhealthy choices - it is also advertising and availability which lead people to canned drinks full of high fructose corn syrup and foods full of trans fats (burgers with transfats and sugar in them are cheaper than those without). Public policy (government subsidies for growing sugar corn) and rampant capitalism (food companies manufacturing with trans fats and high fructose corn syrup for extra profit, unrestrained by a government that is unwillling to put in place basic food safety protections for its unwitting citizens) are at the heart of the problem.

 

[Perrotfish]

It is unreasonable for anyone to be able to walk in and be seen without making sure of their ability to pay as well. You can't go to the repairman with a bad transmission and force them to fix it without being able to pay for it. One difference is, the repairman has to give you an estimate before work begins. If we gave estimates, suddenly people would be refusing tests due to cost, and with the liability nightmare in this country, the lawsuits would likely go up.

Why would lawsuits go up? Our patients sign AMA forms all the time, and we let them go. This would be a new form of AMA

As far as "crappy" insurance policies or whatever, I didn't force them to buy that insurance. They were supposed to read the deductibles and out of network costs of the policy. .

You're missing the point. The problem isn't that they didn't read the deductible or understand their coverage, its that a full coverage policy (3K/year/person if you're young and are lucky enough to have had no previous health problems, WAY more if you have any medical problems) is just way to much money for the average American budget, let alone for those americans whose budgets are below average. Which would be fine, if they could price out their therapies and budget for their care like any other product, but healthcare alone is given the option of sending a patient a bill for a sum that he didn't agree to pay and then holding him responbile for paying it.

Its not like there aren't cash pay systems in other parts of the world. Singapore is generally held up as a shining example of what can happen when you treat healthcare like a business by making people pay cash for their care, and making hospitals advertise their prices like any other business. People make informed decisions about their health, costs get controlled, and they have healthcare outcomes on par with europe for only about 5% of their GDP. So why shouldn't hospital be held to the same basic standards as other buisness in this country? If no one is paying for their care anyway, what would it change if hospitals clearly posted their prices? If they are paying for their care, why is it alright for hospitals to gouge their customers in a way that's illeagal in every other industry?

Wow. Sorry man, but you're dead-wrong here.

If I'm dead wrong then why don't aggressive biling practices get better when the hospital caters to a more upscale (private insurance) demographic? After all, they're running in the black, they're paying out enormous profits to their shareholders (or their boards, if they are what we laughably call a non-profit) but the ER's insane billing structure doesn't disappear. If anything they're worse, because it makes much more sense to hire aggressive collections departements when the majority of your patients have real assests to sieze.

Businesses make money, and hospitals (even nonprofits) are businesses. If you let them send their customers a bill for 'everything you own' then that's the bill their customers are going to get.

As far as why we get fat ? Calories in, calories out, man. Nobody chooses your behavior but you

Again, I highly recommend Taubes's book 'why we get fat'. I think the balance of research right now does not support the calories in/calories out view of obesity.

 

[Rendar5]

You do realize that AMA forms don't prevent lawsuits, right? They provide for a better defense, but they won't prevent you from being named.

 

[deleted65604]

One of the side effects of capitalism is that not everyone has the same degree of choice.

One of the side effects of socialism is that nobody has any degree of choice, regardless of their ability. Only the ruling elite have any freedom, one of the ironies that opponents of capitalism never seem to realize, until it is too late.

 

[shopsteward]

One of the side effects of socialism is that nobody has any degree of choice, regardless of their ability. Only the ruling elite have any freedom, one of the ironies that opponents of capitalism never seem to realize, until it is too late.

This reply sets up a false opposition that was not in my post - saying that capitalism has side effects is not the same thing as advocating socialism.

A society which cannot acknowledge that capitalism has undesirable effects as well as desirable ones will be unable to manage itself so as to maximise the desirable effects and minimise the undesirable ones.

 

[deleted65604]

This reply sets up a false opposition that was not in my post - saying that capitalism has side effects is not the same thing as advocating socialism.

A society which cannot acknowledge that capitalism has undesirable effects as well as desirable ones will be unable to manage itself so as to maximise the desirable effects and minimise the undesirable ones.

You are clearly an anti-capitalist, based on your previous posts. Advocating for socialized medicine is advocating for socialism. Anti-capitalists are often socialists. Sometimes they are anarchists, communists, Democratic socialists, and sometimes, they haven't thought through the issues.

 

[shopsteward]

You are clearly an anti-capitalist, based on your previous posts. Advocating for socialized medicine is advocating for socialism. Anti-capitalists are often socialists. Sometimes they are anarchists, communists, Democratic socialists, and sometimes, they haven't thought through the issues.

Wouldn't describe myself as anti-capitalist, and wouldn't have thought my previous posts supported that. Don't think I've advocated for socialised medicine either. I do agree though that the application of those terms tends to be on a sliding scale depending on the starting point of the user.

 

[RustedFox]

If I'm dead wrong then why don't aggressive biling practices get better when the hospital caters to a more upscale (private insurance) demographic? After all, they're running in the black, they're paying out enormous profits to their shareholders (or their boards, if they are what we laughably call a non-profit) but the ER's insane billing structure doesn't disappear. If anything they're worse, because it makes much more sense to hire aggressive collections departements when the majority of your patients have real assests to sieze.

Businesses make money, and hospitals (even nonprofits) are businesses. If you let them send their customers a bill for 'everything you own' then that's the bill their customers are going to get.

They dont' get better, because most of those "upscale" hospitals belong to larger groups that have several "perennial loser hospitals" on the dockett. The solution to pollution is dilution.

Again, I highly recommend Taubes's book 'why we get fat'. I think the balance of research right now does not support the calories in/calories out view of obesity.

Meh. Might be worth a read, might not be. Junk science is all over the place. I've got my own book entitled "why we get fat". Veers and docB released their editions last year. I've also got another book entitled "Lining up your fourth putt."

 

[deleted109597]

Again, I highly recommend Taubes's book 'why we get fat'. I think the balance of research right now does not support the calories in/calories out view of obesity.

Tell me how this research shows the human body violates the laws of physics.

Sure, some people might burn fewer calories due to endocrine issues as well as lack of exercise, but it is physically impossible to eat fewer calories than you burn and still gain weight. Other than dust that settles on you.

 

[WilcoWorld]

Meh. Might be worth a read, might not be. Junk science is all over the place. I've got my own book entitled "why we get fat". Veers and docB released their editions last year. I've also got another book entitled "Lining up your fourth putt."

I found it to be a convincing argument, in spite of the fact that I shouted "You can't violate the 1st law of Thermodynamics!" at multiple recommendations before I finally read it for myself. That's why I wont try and convince you, I'll simply recommend that you check it out for yourself.

(Spoiler: He doesn't violate Thermodynamics)

 

[WilcoWorld]

Tell me how this research shows the human body violates the laws of physics.

Sure, some people might burn fewer calories due to endocrine issues as well as lack of exercise, but it is physically impossible to eat fewer calories than you burn and still gain weight. Other than dust that settles on you.

The amount of calories one burns in a day is highly variable and is far more influenced by our endocrine system than it is by our gym membership (take myxedema coma for example).

So, if you burn 1800 calories/day (as a result of lethargy and inanition, which of course, none of our obese patients have) than eating 1850/day will allow you to gain weight.

 

[RustedFox]

I found it to be a convincing argument, in spite of the fact that I shouted "You can't violate the 1st law of Thermodynamics!" at multiple recommendations before I finally read it for myself. That's why I wont try and convince you, I'll simply recommend that you check it out for yourself.

(Spoiler: He doesn't violate Thermodynamics)

Spoilers welcome... but the following simple observation/generalization remains:

Childhood DM and obesity rates are at an all-time high. Ever. I'm sure this has *nothing* to do with the fact that we're packing eleventeen gillion calories into every morsel of food that we can. And that kids spend more time in front of "Halo 7" than they do playing third base.

Its time to make adolescents "work for their food" again. Maybe that's a bit harsh. Maybe it should be "work for something again"... but... Might solve a lot of other problems along the way. I'm not saying that we return to generations gone by where children were the breadwinners of the household, but... maaaan.

Fewer calories all around and a better work ethic might be a great thing for this country.

Austerity breeds excellence.

 

[WilcoWorld]

Again, I'm not going to try and convince you. It's a paradigm shift, so changing minds will require a more sustained inquiry than is afforded by this forum. Your observation that childhood obesity and diabetes are increasing is true. What's interesting is that these phenomena (and several others) are far better explained by Taubes' theory than they are by the current "common sense". What's important is that, if Taubes' is right, the currently prevailing ideology is making the problem worse.

As a non-scientific, anecdotal aside - after reading the book about 2 months ago I've lost about 10 pounds so far. I also feel more energetic and I am hungry less often.

In closing - read it for yourself. You might be surprised.

 

[Birdstrike]

spoilers welcome... But the following simple observation/generalization remains:

Childhood dm and obesity rates are at an all-time high. Ever. I'm sure this has *nothing* to do with the fact that we're packing eleventeen gillion calories into every morsel of food that we can. And that kids spend more time in front of "halo 7" than they do playing third base.

Its time to make adolescents "work for their food" again. Maybe that's a bit harsh. Maybe it should be "work for something again"... But... Might solve a lot of other problems along the way. I'm not saying that we return to generations gone by where children were the breadwinners of the household, but... Maaaan.

Fewer calories all around and a better work ethic might be a great thing for this country.

Austerity breeds excellence.

+1

 

[Birdstrike]

Again, I'm not going to try and convince you. It's a paradigm shift, so changing minds will require a more sustained inquiry than is afforded by this forum. Your observation that childhood obesity and diabetes are increasing is true. What's interesting is that these phenomena (and several others) are far better explained by Taubes' theory than they are by the current "common sense". What's important is that, if Taubes' is right, the currently prevailing ideology is making the problem worse.

As a non-scientific, anecdotal aside - after reading the book about 2 months ago I've lost about 10 pounds so far. I also feel more energetic and I am hungry less often.

In closing - read it for yourself. You might be surprised.

Since the thread has been hijacked already, I'ill jump in.

I don't know anything about Taubes theory (never heard of it), but I have counted calories for weight loss before and I lost weight exactly as predicted and very reliably.

I think most diets are just marketing projects designed to sell the latest author's book and idea.

They all follow one theme: if you work the jaw muscles a lot less, and all the other muscles a lot more, you'll get fitter.

The all have you eat LESS of something, which overall results in less overall food being funneled down said gizzard. There's no magic to any one money-making diet marketing-gimmick. They all work, because they make you eat less...of something.

Pick what you want to eat less of: carbs, protein, sugar, fat, whatever. Pick one and stick to it.

Eat less and move more. It works.

 

[RustedFox]

Eat less and move more. It works.

Its that simple.

Less Mario Tennis. More actual Tennis.

 

[Old_Mil]

Yep. Intentionally so.

I want to get everyone to THINK about it. Not just "sit back and believe because it feels good"... but to actually critically think about their everyday practices.

No you dont't. If I think about it, I realize that I have to go to work this weekend. At work I will be running around spending tens of thousands of dollars ensuring that the deepest parts of the gene pool don't die. So by going to work I am actually ruining the human race. Like I said, don't think about it.


Sent from my A110 using Tapatalk 2

 

[RustedFox]

No you dont't. If I think about it, I realize that I have to go to work this weekend. At work I will be running around spending tens of thousands of dollars ensuring that the deepest parts of the gene pool don't die. So by going to work I am actually ruining the human race. Like I said, don't think about it.


Sent from my A110 using Tapatalk 2

Nope. Think about it more, then.

Just what aaare we doing at work every day ? There's enough outrages like this to make us have to (eventually) step back and say:

"Nope."

I'm not suggesting that you criminally neglect your patients and not deliver care, but eventually, something has to change.