73% of Americans would prefer to die at home; in Massachusetts only about 20% do. We can do better. The first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one goal; to help start the conversation about end of life expectations. The idea is simple. Create a tool to get people talking. One Slide, with just five questions, to help us talk with each other and our loved ones about our preferences.

We’re asking you to share this One Slide wherever and whenever you can: at a presentation, at dinner, at your book club. Let’s start a global discussion that, until now, most of us haven’t had. Commit to being able to answer these five questions about end of life experience for yourself and for your loved ones. Then commit to helping others do the same.

Alexandra Drane and the Engage With Grace team

Request: If you plan to try to answer these questions with family members during the Thanksgiving holiday, and wouln’t mind having a reporter listen in and record part of the conversation, please send an email to Martha Bebinger (marthab@bu.edu). Thanks.

When the Obama administration and the Congress take up health reform in 2009, one of the most contentious issues is likely to be whether to include an individual mandate (IM) in any proposal to expand coverage. When Chapter 58 passed, I was not a fan of the IM. But I’ve since had something of a conversion. While I don’t yet fully embrace the IM, I do think it’s played a much more important role than I expected in the coverage expansions in Massachusetts. And the experience here with designing and implementing the IM holds important policy and political lessons that should inform the debate on whether or not to include an IM in national reform.

Back in 2006, I knew the policy arguments for the inclusion of the IM in our reform law. In particular, the Urban Institute had shown in its Roadmap to Coverage project for the Blue Cross Blue Shield of Massachusetts Foundation that a voluntary insurance system would not get us close to universal coverage, even with a much stronger employer pay or play requirement than was ultimately included in Chapter 58. Without an IM, many people would not take up employer coverage that was available to them and others would not purchase individual coverage even if it were affordable, particularly younger people. Read more…

There is more today about the impact of Medicaid reimbursement rates and state budget cuts on Cambridge Health Alliance, the network that includes hospitals in Cambridge, Somerville and Everett. CEO Dennis Keefe sent this letter to staff today.

Dear Staff,

As you may have noticed, an editorial called “Unkindest Cuts In Healthcare” in today’s Boston Globe takes aim at the state’s emergency 9C and other cuts and how they have severely, and we believe unfairly, impacted both Cambridge Health Alliance and Boston Medical Center. At the Globe’s invitation, I, along with Doug Bailey, Gordon Boudrow and Donna Fox, visited the Globe on Monday and presented our best case to the paper’s editorial board. It appears we were convincing, as the Globe’s editors seem to understand that there is a serious and perhaps unintended downside to healthcare reform, particularly if it endangers the many who depend on the state’s two safety net hospitals for their care. We hope those who can resolve this tenuous situation receive this message in no uncertain terms.

One unfortunate point was the use of the term “illegal immigrant” when referring to our patient mix. While we stand by our mission of providing health care to all in need, Cambridge Health Alliance provides health care services to many patient populations. Over 85% of our patient care is for those who depend on some form of government health care, with well over 50% relying on Medicaid, Commonwealth Care, or programs for the uninsured. There are many reasons why a stable group of our patients remain residually uninsured and are ineligible for reform’s coverage expansions Read more…

While the state is struggling to finance many programs, health care reform has expanded the state’s responsibility to help those who cannot afford health insurance. Of the state subsidized programs, only one requires an active financial participation on the part of an employer, thereby lowering the state’s burden. Under the Insurance Partnership, an employer requirement provides at least 50% towards the cost of health plans. This allows the state to provide smaller dollar subsidies, ultimately helping more people afford insurance since they can partner with employers to share the cost.

By expanding the Insurance Partnership program, the state would not necessarily be increasing its costs, but instead would be transferring some of its costs away from Commonwealth Care, Premium Assistance, and the uncompensated care pool, in which 40,000 people remain. It would encourage employers to maintain health insurance programs for their employees at a minimum 50% contribution level and would provide a more equitable treatment of similarly situated people in the state.

Expanding the Insurance Partnership requires Legislative reform. Read more…

For Massachusetts’ hospitals, I fear the light at the end of the tunnel may be an oncoming train.

The impact of the overall state fiscal crisis and Governor Deval Patrick’s emergency “9C” cuts is just beginning to be felt, and already the outlook for health and human services is grim. Governor Patrick had no easy choices, and tough cost cutting decisions absolutely had to be made. But hospitals and other health providers are hit especially hard, not only with a disproportionate share of the cutbacks themselves but also with losses of federal matching funds due to reductions in promised Medicaid payments.

Already several hospitals have been forced to lay off staff, and many other are delaying or abandoning planned investments in the facilities’ physical plants and infrastructure. There are dire warnings within the legislature that we may face yet another round of cuts when it reconvenes in January.

As the economy continues to unravel, I fear it could trigger an “every entity for itself” mentality that would spell disaster for the entire health care reform effort. One of the leading of health care reform in Massachusetts has been its collaborative nature. Hospitals and other providers with very different patient populations, market shares and agendas have joined together, along with insurers, businesses and the government to reach compromise. Everyone has made substantial sacrifices for the greater good.

Now, important health programs with long-standing track records and high utilization are disappearing, just as demand becomes even greater. Read more…

It’s a tiny sliver of the billion dollars in budget cuts that Governor Deval Patrick has had to make recently. But the nearly four million dollars being eliminated from programs for the chronically mentally ill have a huge impact on the people who benefit from them.

FRED THYS: The people affected by these particular budget cuts suffer from severe and persistent mental illness: schizophrenia, bipolar disorder, deep depression. Among them, and among the people who help them, there is disbelief that programs that seem to work so well are being eliminated. What’s being cut are those programs that help people with severe and persistent mental illness rejoin the world and stay in it: support groups and job training. Toby Fisher is the Massachusetts policy director of the National Alliance on Mental Illness.

TOBY FISHER: I truly fear without them, you’re going to see more people going into the emergency room, more people going into the in-patient hospitalization, and potentially hurting themselves, because they have really learned how to live in the community with these supports, not live in the community without these supports, so I think it’s pretty scary.

THYS: Providers say about 2600 people are affected by the cuts. In a state of more than six million people, it’s not a huge number, but they expect to feel the cuts deeply. Bill Santoro suffers from severe depression and anxiety. Every day, he goes to a day care treatment center in Somerville.

BILL SANTORO: These people go there to stay off the street and they can talk to one another because they have the same illnesses.

THYS: The center has support groups for people who are afraid of relapsing, a yoga group to foster relaxation, and on Fridays people make lunch together. The center closes next week, and Santoro is scared. Read more…

This is the announcement from the Senator’s office:

Washington, DC— Senator Edward M. Kennedy, Chairman of the Senate Committee on Health, Education, Labor and Pensions, today established three working groups of the committee to deal with critical issues of health reform. Under Senator Kennedy’s direction, the working groups will concentrate on three areas essential to comprehensive reform: (1) prevention and public health, (2) improvements in the quality of care, and (3) insurance coverage. Senator Tom Harkin will lead the working group on prevention and public health, Senator Barbara Mikulski will lead the working group on improvements in quality, and Senator Hillary Clinton will lead the working group on insurance coverage. Senator Kennedy released the following statement:

“Our committee is fortunate to have the services of major leaders who are committed to improving health care for the American people. Senator Harkin, Senator Mikulski, and Senator Clinton have generously offered to step forward and assume an expanded role on critical aspects of health reform. I commend them for their leadership, and I look forward very much to working with them, with all our colleagues on the committee and throughout Congress, and with the Obama Administration to achieve the goal at long last of quality, affordable health care for all Americans.”

Question for readers…is Senator Clinton leading the coverage group or is she the next Secretary of State?

The results of a first-of-its kind survey of Massachusetts physicians about the practice of “defensive medicine” — tests, imaging, hospitalizations, referrals and consultations ordered by physicians out of the fear of being sued — should capture the attention of everyone concerned about health care and its costs in the Commonwealth.

Conducted and sponsored by the Massachusetts Medical Society, the Investigation of Defensive Medicine in Massachusetts has shown that the practice is widespread, adds billions of dollars to health care costs, reduces access to care, and may be unsafe for patients.

The study, which conservatively estimates a portion of these defensive practices to cost a minimum of $1.4 billion annually in the state, is the first to specifically quantify defensive practices across a wide spectrum and among a number of specialties and the first to link such data directly with Medicare cost data.

The findings are consistent with a smaller 2002 study by Common Good, a non-profit, non-partisan legal reform coalition, that reported nearly all physicians and hospital administrators feel that unnecessary or excessive care is often or sometimes provided because of the fear of litigation.

The survey found that 83 percent of physicians reported practicing defensive medicine and that an average of 18-28 percent of tests, procedures, referrals and consultations and 13 percent of hospitalizations were ordered for defensive reasons.

But that’s only part of the story. Read more…

One by one, health care leaders on Capital Hill are filing plans to cover the uninsured modeled on what is happening in Massachusetts. Last week it was Senator Max Baucus; President-elect Barack Obama campaigned on a Massachusetts styled proposal and Senator Ted Kennedy is expected to throw his power behind something similar. But would the state’s health coverage law work on a national scale? We pose that question to people who helped write and others who are implementing the law.

MARTHA BEBINGER: The architects of the Massachusetts health coverage law are proud of what it has accomplished. 440-thousand residents have signed up for insurance since the law was passed two and a half years ago. The state’s uninsured rate has dropped to about 3%…well below any other state in the country.

RICK LORD: But Massachusetts started off in a different place than the rest of the country.

BEBINGER: Associated Industries of Massachusetts president Rick Lord.

LORD: We had a relatively small number and finally we were spending a lot on the uninsured to start with, so we had a lot on the uninsured to start with so we had a lot of money in the system that could be redirected to providing premiums for the uninsured.

BEBINGER: Massachusetts also had overwhelming political support in attempting to be the first state to cover the uninsured. Read more…

Accusations aside, the Sunday Globe’s spotlight piece lets readers in on a secret that most industry “insiders” and policy wonks already know. In the words of Gerard Anderson, Uwe Reinhardt et al from the title of their 2003 Health Affairs article on why we spend so much more on medical care than other OECD countries—“It’s the Prices, Stupid…” Since then, the authors have annually updated their analysis and come to the same conclusion. We actually see doctors less frequently, swallow fewer pills, and use about half the hospital days of most other advanced economies; Americans just pay far more per unit of service consumed than they do.

A comprehensive comparison by the McKinsey Global Institute in January 2007 came to essentially the same conclusion. McKinsey actually breaks down our over-spending by healthcare sector—47% of U.S. “excess spending” (compared to the OECD average) is for hospital care, even though we use less than half the number of days per thousand; 12% of the excess spending is for drugs, even though we fill 20% fewer scripts per person; and 21% of the excess spending is for administration.

Most of this blog’s readers will also be familiar with our nation’s relatively dismal ranking on health status. So, we’re paying more, despite using less and doing worse.

That we pay far more to one hospital than to another may seem unfair,but the real problem is what it says about our healthcare marketplace. Read more…