96% of the people who die in La Crosse, Wisconsin have planned for their death. Across the country about 30 percent of adults have done some end-of-life planning, and even among severely ill people it is only about half.

Bud Hammes, a medical ethicist at Gundersen Health Systems, began in the dialysis center, where only two of 60 patients had directives. He trained nurses to ask every patient; after one nurse went first, others followed and the other La Crosse hospital asked for the training too.

In the Dartmouth data La Crosse spends less per Medicare patient than any of 306 regions. One quarter of health care spending is on the last year of life, and when people are asked ahead of time most choose to stop aggressive treatment, which costs much less.

No. CEO Jeff Thompson says Gundersen loses money on the program: there is no billing code for advance care planning, and the savings go to Medicare and insurers. He keeps it because it is the right thing for patients and the community would revolt if it were removed.

Gundersen helped write a provision paying for advance care planning in the health reform bill, but it was attacked as death panels, with Sarah Palin warning of rationing. The law passed without it but rewarded providers that cut spending, so many now ask Bud Hammes how to do it.