Code Black (documentary)

[Acebecker]

All -

 

I just watched this very interesting documentary at the urging of my brother-in-law.  He is pre-med and not sure where he fits into the grand scheme of things.  Code Black is about LA county hospital, one of the 2% of public hospitals in the US.  It was very interesting and, though I know a fair bit about the plight of the un- and under-insured in our country, it shows me a lot of what our current medical insurance climate has brought about.  It is a great illustration of the fact that increasing access to care by mandating insurance does jack to actually increase access to care.  When I worked in urgent care we took all comers and I felt similar to the residents in the film, and I almost wish I could go back to it.  There is a huge need. 

 

Anyway - I want to start a discussion about what we as a profession can do (or are doing) to curb this problem of urban and underserved ER overcrowding.  The safety net is broken.  How do we fix it?

 

[davidccs]

People want your medicine like they want their McDs. They want it cheap, they want it at all places, and they want it NOW!

The thought that ACA would reduce EM overcrowding was naive, they thought people would make appointments with PCPs but didn't realize that people want their illness gone yesterday, so they can party tomorrow.

 

Also the issue of PCPs giving out appointments for 10 days down the road doesn't help, and wasn't addressed... And never mind if you are not a established patient of your PCP, cause that appointment will be 3 months out.

 

EMTALA needs to be revamped, paramedics need to be allowed to deny transport for non-emergencies, insurances need to be removed from the throne, reduce the number of lawsuits (while ur at it, get rid of lawyers all together), tuition needs to be reduced and capped, expand the role of practitioners, and expedite the training of PCPs.

[Acebecker]

So you are saying that the entire problem with the healthcare system is that people don't take responsibility for their own health?  I don't necessarily disagree with the premise, but I would not agree that it is the entire problem with the healthcare system especially in places that are served by hospitals like LAC-USC. 

 

I agree that paramedics ought to have some more leeway, but that gets into potential problems - as soon as someone is refused transport for a nonemergent issue and dies there are going to be problems.  (It has happened already and there were big issues). 

 

Insurances do need to be removed from the throne, but not in the way (I think) that you're saying - their CEOs need to make a normal wage and not some horrendously inflated multi-million dollar wage.  Put all the money CEOs make back into reducing the premiums their subscribers pay and a large portion of the problem goes away. 

 

Reducing litigiousness is not feasible but perhaps building in protections for providers is possible.  As you've said, people want to make a million dollars, so they go after deep pockets. 

 

Tuition caps and reductions are not a bad idea, but is this going to solve the problem of access?  I think not. 

 

More practitioners and especially PCPs makes sense, *but there is no drive to get people to go into primary care.*  It is the specialty where you have to work the hardest with the most difficult patients and know the most about the most (unless you turf all complex patients to specialists), maybe excepting emergency medicine and now we're right back to square one.  I would propose that even we as providers are not accepting enough responsibility - I'm not saying we need to accept more than the patient does - by not being willing to put ourselves on the line for other people. 

 

The EM residency docs in the documentary seem to understand and they seem to truly believe the medicine is a profession of service.  Service to others, service at the expense of our own comfort.  Primary care is in many ways the embodiment of that, or it should be. 

[True Anomaly]

 

 

More practitioners and especially PCPs makes sense, *but there is no drive to get people to go into primary care.*  It is the specialty where you have to work the hardest with the most difficult patients and know the most about the most (unless you turf all complex patients to specialists), maybe excepting emergency medicine and now we're right back to square one.  I would propose that even we as providers are not accepting enough responsibility - I'm not saying we need to accept more than the patient does - by not being willing to put ourselves on the line for other people. 

 

Emergency medicine is one of only two specialties that is mandated by the government to see any and everyone who walks in the door- and it's an unfunded mandate, at that.  And frequently when we have underinsured or uninsured patients who have serious issues that we cannot fix in the ER- both we and the patient end up completely frustrated.  

 

I cannot treat their cancer

 

I cannot surgically repair their broken bones and follow them to ensure they heal well

 

I cannot amputate their gangrenous toes

 

I cannot manage their lupus, pulmonary fibrosis, **insert any name of chronic disease here**

 

And I cannot force anyone to treat these people because "well, they just can't pay".  

 

And, I also find, I'm seeing many patients who haven't the first clue as to how the healthcare system actually works and try to be their own advocate, because we are raising a section of society that believes that "If I get sick, I just go to the doctor- aka the ER".

 

My point behind this is that ER is broken because there are many people who don't understand what our role in the medical world is, combined with specialists who won't treat patients who need it because there is zero financial incentive to do so.  So I echo your point about other specialties, including primary care, that maybe aren't doing enough to serve the greater needs of patients.  And yes, I will throw primary care into this mix as the problem is not just with uninsured patients who don't have a primary care doctor- it's patients being referred from their PCP's office to an extremely overcrowded ER to get a test that isn't emergent "because I don't want to wait", when their expectations should be managed better.  And if it's hard to manage a patient's expectations in a PCP office  because the patient's experience is starting to be tied to reimbursement, then the problem may fundamentally lie with the fallacy of the patient's opinion of their care being tied to a financial goal.

[Reality Check 2]

I have not seen the documentary. I hope to soon.

 

What has always bothered me about Affordable Care Act was that NO ONE TOLD THE PUBLIC that just because you sign up for one of these policies doesn't mean ANYONE will actually take the insurance, that anything is covered and that there simply aren't enough PCPs in the US to handle these 33 million some odd people.

 

My office cannot take some of these plans - the contracts are heinous, the reimbursement is punitive (it costs US to see some patients), the formularies are a joke and absolutely ZERO specialists will sign up on the plan.

 

Some of the plans won't cover basics like mammography, colonoscopies but the patients don't want those services - I have been asked for gastric bypass, cosmetic surgery, weight loss hokey plans,  naturopathic referrals and total joints - all in people who aren't working, don't plan to work and don't participate in their own health anyway. My opinion is harsh - if a patient won't participate in basics such as glucose screening, lipid screening, PSA, mammograms, PAP smears and the like - no access to "frills". Then I get to tell the patient that they can want all these things but ZERO specialists take this insurance and those services aren't covered anyway. Their response - "then why did I get this policy".

 

The entire US system is a mismatch. 

 

Insurance companies are allowed to operate at embarrassing profit margins and pay 7 figure bonuses to execs while routinely denying services to premium paying citizens. 

 

Hospitals are often for profit systems - which, naive or whatever - is just wrong.

 

We truly have one of the most unhealthy populations of organized countries in the world.

 

PCPs make the least, need to do the most, need to know the most and there aren't enough of us - PERIOD.

 

More US medical grads than residency positions.

 

The fewest number of residents choosing primary care and psychiatry.

 

No docs = No PAs under our current structure.

 

Insurance companies dictate access to meds. Brand is NOT always better but sometimes necessary. Generic drug makers have quadrupled their prices in the past 10 years. Some idiot without medical knowledge has written a cookbook about what meds to use for what without knowing the patient, the situation, etc.

 

Patients think medicine is McDonalds or, better yet, Burger King - I want it my way, now, fast, no inconveniences for me such as diet, exercise, self responsibility, etc.

 

Legislators on a national level are mostly 1%ers who have no idea what anyone else has to do to get medical care, a prescription, an MRI, physical therapy, etc.

 

Folks like Dr. Oz messing up any evidence based medicine we might be trying to utilize. I hate the mantra "evidence based" because - well - how else do you think I learned medicine over these past 25 yrs? I don't pull treatment plans out of my shorts.

 

Our society has created an environment where being sick is not allowed. Healing is not allowed. Staying home with sick kids is not allowed. All evidence of dysfunction has to be obliterated NOW.

 

So, I love taking care of patients. Our system is just flat busted. Top down issues, no communication, little common sense, disgusting profit by the 1% - all extinguishing the desire by many to become PCPs in any field. 

 

The system can't stop long enough to dictate a fix. I have no miracle answers - but would love to participate in a revolution of sorts.

 

My very old Monday 2 cents.....

[gcox87]

Did I just hear a mic drop?

[Acebecker]

Did I just hear a mic drop?

 

I'd say that was a thorough and experienced evaluation of the current state of the healthcare system in the US. 

[Asclepius]

I have not seen the documentary. I hope to soon.

 

If anyone would like to see this documentary I have it uploaded to my cloud. Shoot me a pm with your email address and I can send you a view link. It's a thought-provoking piece. Also, it's absolutely unfathomable how broken our healthcare system truly is. I'm glad this documentary sheds light on it. 

[Successfactor]

If anyone would like to see this documentary I have it uploaded to my cloud. Shoot me a pm with your email address and I can send you a view link. It's a thought-provoking piece. Also, it's absolutely unfathomable how broken our healthcare system truly is. I'm glad this documentary sheds light on it.

Just watched it on NETFLIX

 

Sent from my LG-H631 using Tapatalk

[Acebecker]

Here's my current theory about how to fix the current medical system: 

 

 

 

 

That pretty much sums it up.  Can it be fixed?  Honestly, so many things are broken that I think it's going to have to collapse before we can start to build it back up again.  The only alternative I can see to a total collapse is a single payer system.  Here's the thing about a single payer system - it looks precisely like the situation faced by LAC-USC, only it will be more widespread. 

 

I really cannot see our way through this. 

[Reality Check 2]

Could we ever have a system like Canada, England, Australia or Germany?

 

It would put commercial insurance into a niche market like BUMPR in England where you can buy "better" insurance but it would likely put 2/3 of the insurance companies out of business and shut down some 1% CEOs and execs.

 

The US public is so enthralled with Donald Trump and his renegade process that I doubt they could see any logic in a national health system and overall better citizen health.

 

I wouldn't mind working in a single payer system if the wages were fair - I obviously did not go into this to be a millionaire......

 

What would it take to introduce a single payer system into this country?

[sas5814]

All -

 

I just watched this very interesting documentary at the urging of my brother-in-law.  He is pre-med and not sure where he fits into the grand scheme of things.  Code Black is about LA county hospital, one of the 2% of public hospitals in the US.  It was very interesting and, though I know a fair bit about the plight of the un- and under-insured in our country, it shows me a lot of what our current medical insurance climate has brought about.  It is a great illustration of the fact that increasing access to care by mandating insurance does jack to actually increase access to care.  When I worked in urgent care we took all comers and I felt similar to the residents in the film, and I almost wish I could go back to it.  There is a huge need. 

 

Anyway - I want to start a discussion about what we as a profession can do (or are doing) to curb this problem of urban and underserved ER overcrowding.  The safety net is broken.  How do we fix it?

If you have the heart for that kind of work I'd encourage you to do it. I think there is a special place in heaven for people that do. I did for a couple of years and any sense of helping was totally overwhelmed by what seemed to be the futility of it and the difficulty of the patient population in general. As for mandatory insurance helping anyone I haven't seen it. I'm sure there are some positive stories. Mostly I saw folks who were making 25k-35k a year paying $900/month for insurance with a $5000 deductible. It didn't help..just made them poorer.

[GreyhoundGirl]

I am going to get an Obamacare plan when I start school- God help me! I already know I'm going to have to change my PCP and will be getting my brand name script from across the border...

[Acebecker]

sas5814 -

 

I would like to think that I do have the heart for it, but who can really know until they get there?  The biggest issue that I face is geography.  I don't live near a county hospital, I don't intend to move because of my family.  Perhaps when my kids are out of school, but that's a loooooong way off. 

 

So then the question is what can I, in my tiny part of the world, do to help fix this problem? 

 

I can devote myself to primary care and to hell with all the challenges I'll face.  I can study my butt off so that I'm good at my job, so that I know enough about enough to keep my patients healthy.  I can avoid sending them to the ER and work them into my schedule; stay late if need be.  Be on call from time-to-time. 

 

I don't feel like primary care should be the death knell for work-life balance.  It certainly would not be if more people were doing it. 

 

I don't know if these are the answers, but I feel that if more of us took this approach there would be a dent made.  Doctors, too.  We're all in this together. 

[cc56]

There are soooooo many problems with our health care system.  I don't think legislation can fix it personally.   As far a single payer system....   I think VA when I think single payer system.  Who thinks that the VA is the pinnacle of health care?  Who would give up their company sponsored health care for VA care?  You can almost throw in Indian health services in the mix too.  

 

In my opinion the hardest part will be the patients.  No one is happy when they have to wait, and EVERY one of their problems has to be addressed now!!  If we go to a system like the VA the patients will have to understand that everything takes time.  MRI (unless a TRUE emergency) will be 3+ months out.  I don't care if you tore your ACL and are a super duper soccer star who has to play ASAP.  You wait like everyone else, you don't need an ACL to be functional in your ADLs.   Everyone cites Canada.  I dated a travel RN from there.  MRIs are 6 months out.  She can't get speech therapy for her child, they are stuck with one of two doctors who don't care.   They have no life flight where they are at, so farmers who get really messed up have a 2 hours ambulance ride.  just because no one has to pay, doesn't mean it is better.  There is a trade off.  

[GreyhoundGirl]

I watched this last night and can confirm that it is on Netflix. It kept me interested, but I thought it oversimplified things (like how the residents had this great idea and it somehow saved the whole ED...)  I also noticed one of the residents saying "We will see them. Not a nurse or what we call a mid-level provider, but a DOCTOR" Ego much?

[lanime]

Until the perception of healthcare changes, there is little that can be done. When people would rather spend a small fortune on their car, alcohol or cigarettes, but refuse to pay for health insurance (but still expect exceptional care with miracle outcomes)... It's impossible to keep costs down or see improvement.

 

This statement is not meant to be all inclusive of everyone, as I know there are people with need beyond what they can afford and those with the means who make their health a priority.

[lanime]

... We need more Kanye and Bieber songs about healthcare, I guess.

[RuralER/Ortho]

... We need more Kanye and Bieber songs about healthcare, I guess.

.... I don't think the world needs anymore Kanye or Bieber songs period....

[kargiver]

I am about as libertarian as they come, believe in self sufficiency, autonomy, etc.  A better definition even would be a classical liberal, not the liberals or "progressives" of today on either side of the aisle.

 

But the fix is in.  Mandating insurance for everyone is a backdoor way of making this a "right" for everyone.  Until the affordable care act, healthcare was no more a right than being served chicken parm by your own butler every night. You cannot have one without the other.  If you MUST carry insurance, then you have the right to healthcare, plain and simple.  Right now, we are just in the growing pains phase of what the long term goal of this incremental bill really is - single payer healthcare, which sadly (to me), is the only way this ultimately works.  You cannot have 50 different exchanges, with differing plans, docs, PAs and NPs deciding who they will see and not see based on insurance, when in the end this violates the equal protection clause under the 14th amendment.  Its only a matter of time until this occurs, and when it does, the Feds will have no "choice" (understand - this is precisely what they want) to provide single payer coverage for every American and then a secondary market will evolve for further care or other aspects of care not covered.

 

Code Black, although a good documentary on the failures of emergency medicine in this country, only looks at a small slice of EM (public access hospitals) and was also a puff piece for LA county Hospital.  Anyone who knows the CME circuit knows that a lot of the lecturers on the various circuits comes from here, and this was just another piece in that puzzle.  It has a significantly biased view of EM, paints one side of the picture, and should be viewed as such. But for what it was - it was well done.

 

G

[PAtoB]

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