Posted in, written by The Times of Trenton Editorial Board

Like most Americans, you probably hope that when your time is up, you’ll die peacefully in your home, surrounded by loved ones and far away from beeping hospital machines, invasive treatments and the rigid schedules of hospital routine.

If you live in the Garden State, alas, that vision is far from reality.

Citing a 2018 report, the nonprofit New Jersey Health Care Quality Institute notes that at least one in four deaths in our state takes place in a hospital, the third highest rate in the country.

Along with these somber statistics, the institute offered timely suggestions for better tailoring end-of-life care to meet the wishes of dying patients.

These include creating a statewide database to record and keep residents’ requests readily accessible, providing higher reimbursements for consultations about treatment and palliative care, and offering more robust education on the issue not only to healthcare providers but also to the greater population.

That last one is particularly relevant, since the elderly too often drag their feet about having “The Conversation” with their families, or even with their doctors.

In a 2016 poll the institute conducted with Rutgers University, while six in 10 elderly residents responded that it was important to discuss these matters, the same number admitted they had not done so.

Who can blame them? For too many people, just venturing into these waters can be daunting, bringing the notion of death that much closer.

Moreover, while 99-percent of physicians taking part in a recent national poll said these discussions are necessary, fewer than one-third of them said they had received any formal training on conducting them, and a mere 14-percent said they billed for such a consultation.

The institute urges the state to create a comprehensive plan to include New Jersey’s five medical schools, ensuring that all graduates be grounded in having that all-important talk with dying patients.

Dr. Shereef Elnahal, commissioner of the state Department of Health, notes that the department maintains a website with patient forms and other resources to make end-of-life preferences known.

He also says he hopes to see practices followed by the Villa Marie Claire Hospice in Saddle River introduced in other facilities around the state.

Hospices offer palliative care to terminally ill patients, either at home or in a health-care facility. Their goal is to improve quality of life toward the end of that life, while also supporting family members along the way.

Additionally, a new nonprofit called Goals of Care Coalition of New Jersey is bringing together hospital and long-term care leaders, physician advocates, insurance representatives and others to brainstorm ways to ease patients’ final days.

These are encouraging signs that the state is responding to the needs of a graying population.


Adrian Diogo is Director of the Mayors Wellness Campaign at the Quality Institute.

You work in health care policy. Why did you decide to train to become an Emergency Medical Technician and to now volunteer as an EMT?  

I thought that being on the front lines of health care and actually providing care would inform my work in policy. So much of our policy work focuses on the experience of practitioners and I wanted to understand that perspective in a more personal way.

You were required to spend 15 hours in a hospital as part of your training. What did you learn?

Students support emergency department and triage staff with vital signs and patient transport. I gained some understanding of the emergency department. The reports I read and the statistics I see are just not the same as being there and seeing the challenges faced by emergency departments — from hospital utilization to the opioid epidemic. For instance, in my short time in the ER I saw five or six people come to the emergency department to refill prescriptions, even though the hospital has a clinic a few blocks away.

How has being an EMT informed your thoughts on the opioid epidemic?

Seeing a person who overdosed when I am out in the field or in the ER really personalized this crisis and took the issue beyond the statistics. I also spoke to the ER nurses. They give people information to follow up but many of the nurses said we need better ways to connect patients to the services that are out there. There are not enough services, and connecting patients to the services we do have can be a challenge. The nurses said there is not enough follow up after a person is treated for drug overdose in the ER. This is an example of how being an EMT can inform my health care policy work.

What are the other ways your experiences as an EMT will translate to your work at the Quality Institute?

I have worked on CPR calls, car accidents … helped people with difficulty breathing. At the Quality Institute, I work on the Conversation of Your Life program to encourage people to write down their advance directives. But as an EMT I see that if you have a cardiac arrest and we arrive we are required to perform CPR unless the document is available. So I see the complexity of the real world. Another instance are the calls from nursing homes for very minor problems that a nurse or physician on call could handle. But the nursing home calls 911. This adds distress to patients and adds to the cost of health care. I also understand what it’s like to help people when they need you most. There is a lot of critical thinking that takes place as you are transporting people to the hospital. Then later I can consider what is going on at the policy level and connect my experiences to my work at the Quality Institute.

Are there ways you see the work of the Quality Institute play out in health care?

Yes. Here’s one example. In the field, I have seen the results of health care quality measures like the Leapfrog Hospital Safety Grade. (The New Jersey Health Care Quality Institute serves as the Regional Leader for Leapfrog in New Jersey.) Depending on the severity of injury or illness, patients can request to be taken to the hospital of their choice. More often than not, patient hospital choices directly reflect the Hospital Safety Grades. There’s a positive correlation among Hospital Safety Grades and able-patient hospital transportation requests.

My father-in-law is 92 and my mother in-law is 86. Both are active and healthy. Not long ago, our Conversation of Your Life (COYL) program sponsored an event near their home in Fort Lee and I asked them to join me.

We had dinner first and my mother-in-law, who has a keen sense of humor, said we could have a conversation but not that conversation. Talking about end-of-life issues can test the best of us. Yet after dinner we nonetheless gathered in the packed Tenafly Library to listen to Dr. Angelo Volandes, the Harvard physician who argues for patient rights, especially at the end of life. My father-in-law raised his hand with more questions and interest than I expected.  

We stayed up late that night talking and my in-laws eventually shared their end-of-life wishes with me. The next day they called to say, “Thank you.” My husband and I are grateful that our role, perhaps one day, will be to carry out the wishes my in-laws made for themselves — not to figure out what we think they would have wanted. They gave us an extraordinary gift.

COYL, which is supported by funding from the Horizon Foundation for New Jersey, is now in eight counties helping other families have these valuable conversations, and we’re moving into six more counties. We started COYL because data shows that too many people in New Jersey do not die the way they want to die.

Solutions to improve end-of-life care in New Jersey do not require a scientific breakthrough or new billion-dollar drug. We have the ability right now to make a difference.

At the Quality Institute, with support from The Nicholson Foundation, we’ve put together a plan that we know can improve end-of-life care for New Jersey residents and families.

You can read our End-of-Life Care Strategic Plan for New Jersey here. Our plan outlines how more people can have their end-of-life wishes honored. Right now, we have a disconnect. For instance, a poll we conducted with Rutgers Eagleton found that 63 percent of New Jersey adults have thought about their wishes for medical treatment near the end-of-life. Yet 60 percent have no written documents expressing those preferences.

Here’s what our plan calls for:

  • Technology. We need a financially sustainable statewide electronic Practitioner Orders for Life Sustaining Treatment (POLST) registry so patients’ documented wishes are easily available to providers whether the person is in a nursing facility, an ER, ICU or at home.
  • Payment reform. We must reimburse providers for having these valuable end-of-life consultations in Medicaid and the State Health Benefits Program. In addition, we must rethink reimbursement rates for palliative care.
  • Education. We need to equip our health care workers with training about how to have these difficult conversations. That means physician and nursing education during medical training as well as throughout a health care professional’s career.
  • Culture. And, finally, we need to change the culture around end-of-life care and take the conversation beyond the doctor’s office and into the community. We’re doing that with Conversation of Your Life (COYL). COYL involves community leaders, clergy, social workers, public health departments, senior centers and libraries, and county surrogates.

The plan is a call to action for all of us.  Together, we can make New Jersey a model for delivering the type of care that people want at the end of life. Our plan is organized into four sections and shows how all of us — doctors, nurses, health systems, state leaders, community members — can take action. Please read our plan and see where you or your organization can make a difference.

One day, your in-laws may thank you.

Published by Lilo H. Stainton on NJ Spotlight.

Cesarean delivery comes with a number of risks for mothers and babies, including blood clots, cardiac complications, asthma and diabetes.

All 49 of the hospitals that deliver babies in New Jersey have signed on to an initiative to reduce the number of unnecessary cesarean section births, a potentially risky procedure that is used here more frequently than in most states.

The New Jersey Hospital Association announced earlier this month that Garden State birthing facilities will implement additional training, embrace the work of doulas who can provide women comprehensive birthing assistance, and adopt new clinical protocols and monitoring practices based on policies developed by the NJHA’s Institute for Quality and Patient Safety and the state Department of Health. The goal is to cut the number of these procedures by nearly a third.

While C-sections are an important option for some deliveries, experts agree it is essential to limit their use to critical cases — not questions of convenience for the doctor or patient. The practice increases the risk of blood clots, cardiac complications, infection, and pelvic pain for the mother, and can create challenges for future pregnancies. For infants, they can result in breathing problems, asthma, and diabetes, and can lead to more time in a critical-care unit.

“Delivering a baby is one of the most important times in which more medical intervention isn’t always best,” noted NJHA president and CEO Cathy Bennett, the former state health commissioner. “We must approach this challenge as a partnership — with well-trained hospital teams working with well-prepared women and their support teams to ensure that every mother and baby has the very best care without incurring any unnecessary risks.”

C-sections well above target rate

The NJHA said while Garden State hospitals have made some improvements in recent years, its C-section rate for 2016 was 30.3 percent of all births, well above the target 23 percent. Recent findings by the Leapfrog Group, a nonprofit watchdog, based on 2017 data, showed only 9 of the 47 hospitals that shared their results met their C-section goal of less than 24 percent, down from 11 facilities that made the cut in 2016.

Maternal and infant health has become a growing focus recently in New Jersey, where more than 100,000 babies are born each year. While the state has a strong system of public healthcare, and outcomes overall are improving, it has been the subject of recent reports that raise questions about C-sections and racial disparitiesin maternal health, among other things. While overall maternal- and infant-mortality rates are below the national average, black women and babies die at more than three times the rate of their white counterparts — one of the larger gaps nationwide.

Under Gov. Phil Murphy, who took office in January, state officials have devoted new attention to various aspects of maternal, infant, and women’s health. Department of Health Commissioner Dr. Shereef Elnahal has also zeroed in on women’s health, working with community providers to boost awareness and understanding of the issues and joining with hospitals and other clinicians to encourage best-practice protocols.

“Improving maternal and infant birth outcomes is a key priority for the Murphy administration, so we are pleased that all of the state’s birthing hospitals have joined forces with the New Jersey Department of Health and the NJHA,” Elnahal said. By encouraging the use of these best practices and taking other measures, facilities can “ensure that care delivery is of the highest quality when a woman presents for delivery,” he added.

Focusing on first-time moms

The new initiative — announced at the New Jersey Perinatal Safety Conference in early June — is focused on first-time, low-risk pregnancies with a single fetus in the proper position for vaginal birth; mothers who deliver a first child by C-section will usually end up delivering future babies the same way. The project, which began in April and will continue through next year, is part of the larger work of the New Jersey Perinatal Quality Collaborative, a joint effort of the NJHA and the DOH.

The work has begun with additional education for nurses and other staff on modern, supportive labor techniques, including efforts to improve pain assessments and better inform and engage partners and family members. Steps will also be shared about how to integrate doulas with the clinical team and improve communications between all caregivers involved in a birth.

Hospitals will also be asked to adopt proven best-practice strategies and clear protocols for the use of regional anesthesia, like an epidural. Facilities will also need to adopt policies to ensure proper monitoring of all mothers, including low-risk patients, as the labor begins to progress.

The C-section initiative also drew praise from Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, which has worked in recent years with the perinatal collaborative and other experts to improve birth outcomes. Schwimmer said she was pleased to see the NJHA and the DOH working together on the issue — and that hospitals “are acknowledging that there is a problem with C-section rates in New Jersey and acknowledge that they have a key role in addressing the problem.”

“In our work, we’ve seen that physician and nurse leadership is the most important ingredient to improving the outcomes,” she continued, noting that birth teams should discuss each C-section to determine if it is truly necessary. “Also, early and clear communication with patients about their birth plan and setting expectations is also important.”

But Schwimmer said there are other tools providers should deploy to reduce the rate of C-sections even further, like improving communication and health-record sharing between prenatal caregivers and the hospital delivery team. And hospitals should be required by law to report C-section rates to Leapfrog, she said.

In addition, health insurance plans, unions, businesses, and other groups that pay for care — including state and local government, which covers the cost of care for some 800,000 public workers — also “have a role in changing the payment system so the incentives are removed for keeping the status quo,” Schwimmer said, urging them not to reimburse providers for C-sections that are considered early-elective deliveries, or C-sections or induced births before 39 weeks that are not for medical reasons.

Published by Lilo H. Stainton, of NJ Spotlight

New Jersey residents, like most Americans, would like to die at home or in hospice, but many spend their last days in the hospital.  With more than 25 percent of New Jerseyans dying in hospitals, rather than in their own homes, improving end of life care should be a priority. And it is one that can be achieved through some targeted investments, according to a well-respected healthcare consultancy — such as developing a statewide database to keep residents’ requests and wishes readily accessible. The group also called for higher reimbursements for treatment consultations and palliative care, and better education both for healthcare providers and for the public at large.

The recommendations were part of a strategic plan for end-of-life care released Monday by the nonprofit New Jersey Health Care Quality Institute and funded by The Nicholson Foundation, which seeks to expand access to care for vulnerable populations. The institute is hosting a breakfast meeting today to discuss these findings.

The 15-page report outlines ways in which state officials can work with hospitals, medical schools, local communities, and other groups to provide more appropriate — and often less expensive — medical treatments and support services to patients nearing the end. While the state has made some progress towards these goals, the plan suggests more must be done to get these initiatives up to speed.

Home, hospice, hospital

Studies have shown that while most Americans hope to die at home, perhaps with help from hospice care — which focuses on compassion, not cure — far too many end up spending their final days in a hospital, often enduring invasive, costly treatments. This is particularly true in New Jersey, which has the nation’s highest rates of intensive care for Medicare patients and spends more for these treatments than many other states.

“New Jersey performs poorly on end-of-life care compared with almost every other state in the nation. The statistics translate into real people treated with unnecessary and unwanted medical care at the end of their lives,” the institute noted. According to a 2018 United Health Foundation report, at least one in four Garden State seniors dies in hospitals — the third highest rate nationwide — versus 14 percent in states with the lowest number of hospital deaths.

The issue was already on the radar of state Department of Health Commissioner Dr. Shereef Elnahal, who toured the Villa Marie Claire Hospice in Saddle River earlier this year and hopes to replicate their protocols in other facilities. “Far too often, patient preferences for end of life are never documented and are only discussed during a health crisis,” he said, noting that the DOH maintains a website with patient forms and other resources. “Advance-care planning is the best way to make end-of-life preferences known to ensure an individual’s wishes can be fulfilled.”

That said, Gov. Phil Murphy, a Democrat who took office in January, did not choose to commit another $5 million to a hospice-care pilot that was included in the current budget to fund Villa Maria and other programs, a pet project of several powerful state legislators. When questioned by lawmakers, Elnahal said it was one of several tough budget decisions.

A lack of funding is only one hurdle to improving end-of-life care, the Quality Institute report suggests. A primary problem is that seniors themselves, their families, and their physicians are often reluctant to talk about options for end-of-life care, the data suggests.

Difficult conversations

In a 2016 poll with Rutgers University, the institute found six in 10 elderly residents thought it was important to talk about these issues, but the same percentage had not yet had these conversations. A recent national poll showed 99 percent of physicians agreed these discussions were needed, but less than one-third had received any training, and only 14 percent billed for such a consultation, the plan noted.

That dynamic may be starting to change. In 2015, the Quality Institute launched its “Conversation of Your Lifetime” program to help diverse communities spark these discussions, an initiative that is now active in eight counties and soon to expand to several more. Provider groups, like Samaritan Health & Hospice, in South Jersey, have also held workshops to prompt greater awareness about end-of-life planning.

In addition, the Goals of Care Coalition of New Jersey, a nonprofit organization made up of hospital and long-term care leaders, physician advocates, insurance representatives, healthcare quality organizations, aging experts, and public agencies, was created earlier this year to help improve end-of-life care. The coalition held its first meeting in mid-April, when groups nationwide mark National Healthcare Decisions Day.

Simplifying end-of-life planning

State government has also played a role in this process. In 2011 New Jersey passed a law expanding the use of a standardized form, the Practitioner Orders for Life-Sustaining Treatment, or POLST initiative, which allows individuals to record their wishes in a format that can be easily interpreted by healthcare professionals. The law also created a panel of experts, the New Jersey Advisory Council on End-of-Life Care, to guide this process.

But while the advisory council was supposed to issue a report in 18 months, that document is still pending years later, according to the institute; it is now scheduled to be released this summer. And patients and providers have been slow to embrace the use of POLST forms, which are still primarily paper format. A collaboration between the DOH and the New Jersey Hospital Association to create an electronic database with all the POLST information, launched last year, has also faced a rocky start, officials said.

According to the institute’s plan, the POLST database is now in its final testing phase at Hunterdon Medical Center and should be available to all 72 acute-care hospitals within two years; there will also be a mobile app for patients. The initiative, which is privately funded, is estimated to cost each hospital between $6,000 and $14,000 a year and will provide them immediate access to information about a patient’s final wishes.

Elnahal is also focused on improving the use of this database and seamlessly linking these files to other electronic health records, to ensure interoperability. “The Department supports interoperability because it is critical in improving healthcare overall. It is especially vital in end-of-life care because providers need to have access to documented wishes that outline life-prolonging interventions that should or should not be delivered,” a DOH spokesperson said Monday.

To further boost this effort, the Quality Institute recommends the state consider
taking over the POLST database itself, something only a handful of states, including New York, have done. Based on estimates from elsewhere, it would cost New Jersey between $500,000 and $600,000 annually to operate the system.

Insurance for palliative care

The plan also recommends the state expand insurance coverage for palliative care and end-of-life consultations; Medicare began to pay for these conversations in 2016. The institute urged New Jersey to follow California’s lead and allow Medicaid reimbursements for this type of care, something it estimated would cost the Garden State less than $900,000 a year.

In addition, the Quality Institute urges the state to create a comprehensive plan that addresses POLST use and reimbursements and also outlines a strategy for greater public and provider education. It should include the state’s five medical schools to ensure doctors, nurses, and other caregivers are trained in end-of-life conversations, and explore the use of financial incentives, or penalties, to ensure those in practice properly follow the patient’s orders for care.

“By implementing the recommendations set forth in this strategic plan, together we can help New Jersey become a leader among states in end-of-life care,” the institute notes. “A more effective system will not only help patients but also help their grieving families, who may find comfort from knowing the wishes of their loved ones were honored.”

Published by Leah Mishkin of NJTVnews

A new Leapfrog report shows New Jersey hospitals are performing too many C-sections.

The state is in the bottom five in the country in terms of meeting recommended standards.

“For pregnant women, it’s hard because we want to listen to our health care providers and trust them, but we also need to, to the extent we can, arm ourselves with data like looking at the Leapfrog safety information,” said New Jersey Health Care Quality Institute President and CEO Linda Schwimmer.

The report looked at NTSV cesarean birth rates – meaning first time mothers with a single baby at term, in the head-down position, the population least likely to need a C-section delivery.

But the report shows only 9 out of 47 hospitals in New Jersey met the C-section standard rate of no more than 23.9 percent.

Christ Hospital in Jersey City reported the lowest NTSV C-section rate at 14 percent.

CentraState Medical Center in Freehold, on the other hand, performed the highest rate of C-sections in the state at 42.1 percent, far above the recommended standard.

In a statement, a spokesperson for CentraState said the hospital is, “Working with our physicians and clinicians on improving processes to lower the number of C-sections performed.”

“The hospitals that are doing well on this measure, they have weekly huddles. They go over every single C-section in the hospital and they discuss, was this appropriate, did this need to happen, was this avoidable? Sometimes it is the absolutely appropriate procedure to do, but often times it’s not,” said Schwimmer.

Leapfrog Director of Operations Erica Mobley also stressed while there are times when a C-section is necessary and critical to protect the health of both mother and child, in general it’s being used too often for non-medical related reasons, putting everyone at risk.

“Including potential risk of wound rupture, risk of infection and any number of things that can go wrong during a surgical procedure,” said Mobley. “And as for the baby, there are some studies that have shown some difficulty breathing, perhaps difficulty in beginning of breastfeeding and other challenges that can make it more difficult for the infant if a C-section is performed.”

But why is it happening? Sometimes it’s a patient’s choice either for scheduling purposes or for vanity reasons.

But Schwimmer says another reason is a doctor’s time limitations. That’s why she recommends hospitals have appropriate staffing to give women enough time to labor.

“So you’re not rushing to have a women do a C-section because somebody’s going off shift and nobody is coming on to help so we have to get it done now. Or having a C-section because the doctor wants to leave and he or she has been there for 10 hours and he or she wants to go home,” she explained.

Schwimmer says it also comes down to money. That’s why she says to improve C-section rates, hospitals have to change the payment system.

“Right now, there is a financial incentive to have higher C-section rates and to have more days of the infant being in the NICU, so it’s really taking away those financial incentives and putting in place financial incentives where hospitals and physicians are rewarded for having those better birth outcomes,” she said.

But there’s something else women planning to have a baby in the state should be aware of, according to the report — New Jersey has the highest episiotomy rates in the country.

“Which is also an intervention that is done during labor to widen the birth canal,” explained Mobley. “Many hospitals are significantly struggling with very high rates of this usually unnecessary procedure.”

Roughly three weeks after Leapfrog’s report was released, New Jersey hospitals, the New Jersey Department of Health and the New Jersey Hospital Associationannounced they would be collaborating on a statewide initiative to reduce non-medical C-section rates.

All 49 hospitals in the state that offer labor and delivery programs agreed to participate, and they hope to have a 10 percent reduction in NTSV C-sections by next summer.


Erine Gray is the founder of Aunt Bertha, a Public Benefit Corporation.

Aunt Bertha has been called the “Google of social services.” How did you come up with the idea? 

I’m from a small town in Western New York and my mom had Encephalitis, a rare brain disease. She became disabled when I was 17 and she was 47. She could not work anymore and required 24-hour care. We were always a paycheck-to-paycheck family, and her illness made our situation even more complicated. Our family did the best we could to take care of her – we were fortunate to live in a small town with helpful family members nearby, and a low cost of living.

I’ve always been interested in public policy, and shortly after I became my mother’s guardian in 2002 I went back to grad school to get my Master’s in Public Affairs from the University of Texas. I worked in Texas helping governments better deliver on public services. I helped the State of Texas modernize how people find and apply for any of the 143 different State-based government services. And I thought, “How can you take all the agencies, county governments and non-profit programs and put everything in one place?”

OK, why Aunt Bertha and not, say, Uncle George?

We wanted the person in need to feel they were going to a trusted source. I worked in government consulting and so we wanted a play on Uncle Sam. So at first we wanted Aunt Sue. But that domain name was going to cost $3000. So we started using Aunt Bertha, never meaning for it to be permanent. But it stuck. And the best part was that domain name was only $13.00.

In Jersey City, leaders in government said asking people to claim their agency on Aunt Bertha has opened doors to new relationships and enabled cities to strengthen existing relationships. Was that your goal?

 We want people to claim their agency and make sure all the numbers and names and services offered on Aunt Bertha’s listings are correct and up-to-date. But the building of relationships —that’s a great unintended side effect.

What is your sustainability model?

We’re a benefit-corporation. That means we are a business that serves to make a profit and also provide a social benefit. Our social benefit is to make this information available to people in need. If we get enough customers we can sustain our work. Many of our customers are grant funded, and some are large hospital systems and health plans that pay us monthly fees to fund our software creation and data maintenance. We currently have more than 90 customers and are adding new customers every month.

The Quality Institute’s Mayors Wellness Campaign is supporting Aunt Bertha in several New Jersey communities. How is working in New Jersey different from your work in other states?

One of the things I’ve noticed is that as we continue our work in New Jersey and with the Quality Institute we are seeing an uptick in search activity. We’re getting early traction from the health care sector and the ACOs (Accountable Care Organizations). People are working together collaboratively and creatively and we’re fortunate to be a small part of it.

Does Aunt Bertha activity provide a snapshot of local needs?

That is one aspect we envisioned all along. Since we started, we always logged our search data. Our goal was that – some day – as a community we’d see trends about what people are looking for, and what programs were available. Eventually, our goal was to give funders this information so we collectively would have a better understanding of what to fund.

With more than a million users now, we are beginning to see interesting trends. For instance, we see more searches for dental care in states that do not cover dental care for adults on Medicaid. Perhaps someday, our data can be used by communities to better match supply of services, with the demand for those services. That’s our vision for the future.

Last week I traveled to the gymnasium at the Woodbridge Community Center to see Gov. Phil Murphy sign legislation to protect consumers from surprise out-of-network billing.

During the bill signing, Murphy recalled a campaign-season dinner with Sen. Joseph Vitale at the nearby Reo Diner, where Murphy promised to sign an out-of-network bill if the legislature put one on his desk.

And so with a few strokes the new governor did what he promised, despite strong opposition from some quarters. For a decade, the Quality Institute has fought for these common-sense solutions so consumers who follow their insurance company rules do not find themselves suddenly facing absurdly high out-of-network bills.

A few days before the bill signing, I found myself in another gymnasium. I was at Franklin & Marshall College in Pennsylvania to see my oldest son graduate and the rain forced us all into the athletic center. The speaker was New Jersey Sen. Cory Booker, and I hope what he said resonated with the graduates.

I know it resonated with me.

Sen. Booker told the graduates that when they see a problem they should not assume they are powerless. You don’t know the chain of events that may emanate from even the simple act of joining a committee, or volunteering, or having your voice heard in some way — even if it seems others have more money and power than you. “You are powerful,” Booker told the Class of 2018.

I saw connections between these two gymnasium events and I thought of how all of you, our members, have raised your voices and worked for solutions to the problems you see around you — at your own facilities and organizations and more broadly in our state. From public transparency on safety performance to fixing the surprise billing issues, sometimes change seems impossible and everyone has a reason why it won’t happen.  But you are powerful, and together, we are even more powerful. Our collective incremental steps are leading to better health in our state.

As you probably know, last week Governor Murphy also signed two bills that emerged from our Health Care Reform Work Group with Senator Vitale: the state-based individual mandate to stabilize the individual insurance market, and the establishment of a reinsurance program to reduce the cost of insurance premiums. Many of our members participate in a variety of our work groups, where we bring together people from every corner of health care to find solutions to the pressing problems we face.

At the Quality Institute, we’ve advocated for the out-of-network law as well as the individual mandate and reinsurance laws because we believe they will advance our mission to improve health care quality, increase transparency and reduce costs. And in these past few weeks I can see that our voices are being heard.