Last Friday morning, I attended a breakfast hosted by Leadership Howard County that featured a talk by the new president of Howard County General Hospital, Steve Snelgrove.  I found it fascinating.  After a brief introduction, Mr. Snelgrove spent most of his time explaining recent changes in the Maryland Medicare waiver, something I knew nothing about.  He went on to detail two programs that were of interest to him because they were proven to reduce health care costs.  Both require partnership with the faith community--and both raised lots of questions for me.  Unfortunately, the breakfast program didn't include any time for questions and answers.  So, the talk served to begin a conversation that I'll continue here.  

First, a few words about the new Medicare waiver for Maryland.  It could be that most people in this state are already aware of the special arrangement Maryland has with Medicare, but this was the first I'd heard of it.  The waiver, first established 36 years ago, has meant that Maryland hospitals are reimbursed for procedures at the same rate, regardless of insurer, including Medicare.  These reimbursement rates are set by the independent Health Services Cost Review Commission, which has over the years managed to keep increases in cost lower than in other states.  In every other state in the country, Medicare sets its own rate for reimbursement, generally the lowest of any insurer.  Hospitals make up the difference by increasing the rate at which private insurers are billed for the same procedure.

Beginning this past January, Maryland has a new "modernized" waiver.  Now, instead of reimbursing hospitals for each admission or procedure, Medicare will pay each hospital an annual sum based on the population that hospital serves, increasing each year at a rate tied to the growth of the state's economy.

Snelgrove pointed out that this change is an important corrective to the previous system which incentivized hopitalization and testing.  Now, hospitals will have an incentive to keep patients out of the hospital, pushing them to promote wellness and disease prevention in their community.  Snelgrove didn't have a lot of specifics to mention here except to remind each person in the room that they shouldn't regularly eat a breakfast like the one we had just been served.  

Hosptials will also have to cut costs.  Snelgrove had more to say about this point.  He made quick mention of reviewing staffing within the hospital but then mentioned two programs that could make a significant difference.  First, he talked about the need to encourage everyone in the community to fill out Advanced Directive forms regarding their desires for end-of-life care.  He mentioned LaCrosse, Wisconsin, recently profiled by Planet Money on NPR as "The Town Where Everyone Talks About Death".  Ninety-six percent of the people in LaCrosse have advanced directives compared to just 30% of the population nationally.  Not coincidentally, LaCrosse is on the bottom of the list of Medicare spending by 306 regions in the country.

How did this happen?  The Planet Money story gave all the credit to a man named Bud Hammes who is employed by a local hospital as a medical ethicist.  He saw so many families agonize over decisions about the treatment of their loved ones that he decided he needed to take action.  He started promoting advanced directives as a way to help people, hospital patients and their families, not as a way to cut costs for the hospital.  That was an accident.

But now, hospitals all over the country are anxious to replicate what happened in LaCrosse in order to save money.  I understand that--but for that very reason, I think it would be best if campaigns to get people to create advanced directives were not led by hospitals, but by the churches, synagogues and mosques in a community.  And I think we could--we should--do that in Howard County.

If a hospital employee approached a relative or parishioner of mine and offered to help them fill out an advanced directive, I'd be worried.  Knowing that they are under intense pressure to cut costs, I'd worry that each question would be shaped in a way that would encourage each person to ask for less treatment, less intervention.  But churches and other faith communities have no such interests.  In addition, in the context on a faith community, conversations about end-of-life care can be framed in a broader conversation about a person's beliefs and questions about death and life after death.  This conversation can help the person make decisions about their care and treatment not based on fear, but on trust.

The Kittamaqundi Community has long held a call to help people think and talk about death.  Over the years, we've held a number of classes to help members and friends reflect on and prepare for their death.  When I arrived at the church nine years ago, I found a file in the office with each members' name on it.  Inside were outlines for each person's funeral including their favorite songs and readings and other requests.  While I found this a bit strange at first, these pre-planned funerals have been a great help to me over the years.  In fact, they've encouraged me to plan my own.

This emphasis in our community comes out of the particular call of several of our members.  One of our members, Pat Englebach, published a book in 2000 called, "Last Rights:  Taking Care With Your Final Journey" which leads the reader through a series of reflections about the end of their lives including the creation of advanced directives.  Another member, Jack Dunlavey, is one of the chaplains at Howard County General Hospital and teaches the training program for volunteer chaplains which includes much conversation about end-of-life decisions.  Jack has taught our most recent course on death with Carol Lobell, a retired therapist in our congregation.  Bill McCarthy, also a part of KC, sits on the ethics board of the Howard County hospital.  Clearly, we have the ability to take this conversation outside our own community.  I'd like to see us do that.

But churches aren't the only place where people talk about death.  Three days after I heard the NPR story about LaCrosse, Wisconsin, I heard another story about "Death Cafes".  Started by a British web designer named Jon Underwood, these cafes are not a location but an event, a salon as it were, where the subject is death.  Underwood wasn't out to reduce health care costs, but he was interested in making death something that people feel more comfortable talking about.  Inevitably, the conversation expands beyond death.  Underwood says in the NPR story, "When we acknowledge that we're going to die, it falls back on ourselves to ask the question, 'Well, in this limited time that I've got, what's important for me to do?' "  

The movement has spread to the United States including Baltimore where two nurses, Valerie Sirani and Amy Brown, held their first cafe back in June, 2013.  The topic is wide-open and "delicious cake" seems to be a feature.  Because these are "no agenda" conversations, they are different from ones that are explicitly hosted by a faith community.  But they serve another hugely important need--they get the conversation started.  Who wants to host one in Howard County?

I appreciate the prompt from Steve Snelgrove to start thinking about how to engage more people in Howard County in a conversation about death and dying--before they get to the hospital.  I think this is an important way for the community to partner with the hospital to the benefit of everyone.

Tomorrow I'll write about a second proposal Snelgrove mentioned for reducing the cost of health care with the help of the faith community--one that I found much more problematic.