Warning: Spoilers for the Pitt S2 ahead.

LDI Fellows use The Pitt‘s second season to show how fictional storylines often mirror real-world challenges—from a violent assault on an ER nurse to a hospice patient whose end-of-life preferences shift amid great pain, and a near-miss caused by a generative AI charting error. While The Pitt is fiction, the policy implications are very real. 

Hear from LDI experts below. More perspectives will be published here next week.

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The Pitt’s Orlando Diaz Lacks Insurance, Rations Insulin and Nearly Dies—He’s Not The Only One

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In Episode 2, Orlando Diaz is hospitalized with life-threatening diabetic ketoacidosis after he lost his health insurance and began rationing his insulin. Meanwhile, his family earns too much to get on Medicaid. Even though hospital officials make several efforts to lower care costs, he leaves the hospital against medical advice because he cannot afford even discounted care on top of $100,000 in existing medical debt.

Policy Perspective

Meredith Doherty, PhD, LCSW: Mr. Diaz is one of the 26 million Americans who lack basic health insurance, the vast majority of whom (73.7%) are working adults whose employers do not provide affordable coverage. Nearly 2 million uninsured workers have diabetes, a chronic illness that can be managed effectively with common treatments, like insulin. Without health insurance, though, many people with diabetes go untreated despite the availability of safe and effective treatment. As seen in this episode, untreated diabetes can quickly snowball into catastrophic health conditions that require critical, emergent health care needs. The sad irony, and frankly the most frustrating aspect for me as a scientist and advocate, is that the overall cost to society of untreated diabetes and other chronic health conditions is many times greater than that of providing universal access to health insurance and routine care. 

The Pitt’s ER Overflows With Patients: Why You Can Wait Hours for Care

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Episode 4 shows an ER strained beyond capacity as a nearby hospital closure triggers a surge of patients, making staffers to treat nonstop emergencies with little time and few resources. Throughout the series, patient care in the ER often occurs in hallway beds due to limited beds, underscoring a frequent theme of ER overcrowding in the second season.

Policy Perspective

Austin Kilaru MD, MSHP: Our society takes for granted that when we get sick, we can go to an emergency room and receive immediate attention. But that is often not true. You may have to wait hours to receive care, even if you are truly sick. Why? It is not because ERs, and their dedicated staff, are dysfunctional. In fact, physicians and nurses pull off the impossible every day, helping as many patients as they can. The reason is that the ED has to keep patients that need to be admitted but have no hospital bed to go to. Because patients cannot leave the ED, the lines then spill out the front door. And patients have worse outcomes. If we ask why again, there are deeper reasons — all of which demand that we take action.

Our payment system demands that hospitals keep all their beds full, to make enough money to keep the lights on. Our inability to keep people healthy — through strong primary care, population health, and behavioral health services — fuels the demand for ED and hospital services. And our inability to send patients from the hospital back to their homes or nursing facilities further clogs the system. On top of all of this, the misunderstanding of this problem among health care leaders, along with the lack of good quality measures, aggravates the underlying challenges.

The obvious response — build more hospital beds — will not work without taking other actions in parallel. Building beds increases costs, which raises pressure on hospitals to make more money, which leads to more high revenue procedural and elective care, which attracts more patients that fill the new beds. So — we circle back to the same place but now spend even more money. It is important to note that while some hospitals, often large academic health systems, are overwhelmed, other hospitals struggle to find enough patients to stay open.

We need to do three things. First, pay hospitals in a new way that does not force them to do more but instead keep beds open. Second, create public quality measures that affect hospital accreditation and payment, forcing leaders to act. And third, strengthen our outpatient systems to not only keep people healthy but deliver timely care when people do get sick — new alternatives to EDs and hospitals. These solutions are not easy, but as seen in The Pitt, we have no other choice.

The Pitt: Street Care is Crucial to Improving Health Care Access for All

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In Episode 11, Dr. McKay and the street medicine team treated Kiki, an unhoused person who uses intravenous drugs. Kiki asks for Dr. McKay to meet her in the park for an issue with a wound from xylazine use, which is beginning to smell. Kiki admits to using “tranq,” xylazine’s common name. Dr. McKay and a medical student clean the wound with saline and give Kiki antibiotics and supplies to treat the wound on her own.

Policy Perspective

Eleanor Turi, PhD, RN: From a policy perspective, this episode underscores the critical role of delivering wound care outside of the traditional medical system. Street medicine is a health delivery model that brings direct medical care to unsheltered people experiencing homelessness. At the state level, policymakers can strengthen street medicine organizations by supporting implementation of new Medicaid street medicine billing codes, enabling teams to bill for their services. Financial viability may improve by including nurses as eligible providers, my work suggests. Also key are expanding the range of reimbursable services, simplifying billing processes, increasing reimbursement rates, and supporting bulk funding mechanisms. At the local level, policymakers should continue to support, not reduce or restrict, harm reduction services like street medicine teams and syringe services programs, which are essential to maintaining accessible wound care for people who use drugs. Finally, payers can support innovation by reimbursing telehealth models that extend specialty wound care into community settings; I am currently testing one such tele-wound care consultation model through the Penn Nursing Innovation Accelerator. 

Read more about what The Pitt got right and wrong about xylazine wounds on Eleanor’s Substack.

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The Pitt‘s Hospice Case Challenges “Dying at Home” as the Only Standard

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In Episode 10, Roxie, 42, a hospice patient with advanced lung cancer, debates whether to return home to die as her husband wishes. Dr. Robby asserts supporting her choices is the best thing they can do for her. She ends up dying in the hospital with her family by her side.

Policy Perspective

Katie Auriemma, MD, MSHP: Dying at home is often touted as a central part of a “good death”. Dying at home is cited as the majority preference of Americans. Hospital deaths, particularly for patients enrolled in home hospice, are often considered a system failure. However, preferences for end-of-life care are not always stable, and the reality of caring for someone at the end of life in the home setting, even with supportive services, can be incredibly challenging for patients and families. The importance of eliciting and honoring shifting preferences over time or with changes in health status is central to the provision of goal-concordant care. On a system level, we need better methods to identify and measure delivery of goal-concordant care so that “place of death” is not the only marker of a “good death.”

ER Nurse Assault in The Pitt Shows U.S. Hospital Safety Gaps

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In Episode 11, Emma checks on a sleeping patient who was taken to the hospital for combative behavior and intoxication. The patient wakes up, confused and still combative, and places Emma in a chokehold. She cannot call for help because the room’s door is closed.

Policy Perspective

Karen Lasater, PhD, RN: Nurses in emergency departments (ED) are assaulted on the job more than nearly any other professional in any industry. In the absence of national standards to prevent workplace violence against health care workers, legislative action is progressing piecemeal across states, or at the discretion of hospital administration, making protection for health care workers uneven. Nurse understaffing in hospitals has been associated with greater incidence of workplace violence and can be addressed through policy mandates to ensure safe care environments for clinicians and patients alike. Understaffing of nurses in inpatient units contributes to bottlenecks in the ED, with patients boarding in hallway beds and leaving before care is finished due to frustrating care delays in the chaotic and high-stress environment. For these reasons, ED clinicians endorse safe nurse staffing standards (among others) as a workplace violence prevention strategy.

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