Bree Collaborative Meeting -- Minutes
September 30, 2011
Members Present:
All present
Steve Hill, Bree Collaborative Chair
Bruce Smith, MD, Group Health Physicians
Carl Olden, MD, Washington Academy of Family Physicians
Eric Rose, MD, Fremont Family Medical
Gary Franklin, MD Washington State Labor and Industries
Greg Marchand, The Boeing Company
Jay Tihinen, Costco
Jeff Thompson, MD, Washington State Health Care Authority
Jodi Joyce, RN, Legacy Health
Joe Gifford, MD, Regence Blue Shield
John Robinson, MD, Molina
Kerry Schaefer, King County
Mary Gregg, MD, Swedish Medical Center
Peter Valenzuela, MD, PeaceHealth
Rick Goss, MD, Harborview Medical Center
Robert Mecklenburg, MD, Virginia Mason Medical Center
Robyn Phillips-Madson, DO, Pacific NW University of Health Sciences
Roki Chauhan, MD, Premera Blue Cross
Stuart Freed, MD, Wenatchee Valley Medical Center
Susie Dade, Puget Sound Health Alliance
Tom Fritz, Inland Northwest Health Services
Tony Haftel, MD, Franciscan Health Systems
Guests
Terry Rogers, MD, Foundation for Health Care Quality
Jason McGill, Governor’s Office
Leah Hole-Curry, L&I (for AIM Collaborative)
Kristin Sitcov, WSHA
Bob Perna, WSMA
Wilma Eby, Dept. of Retirement Services
Bill Stryuck, Johnson & Johnson
Dena Searce, Medtronic
Bill Alkire, lobbyist
Welcome & Introductions
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Steve Hill brought the meeting to order at 1:30 p.m.
The agenda for the day, materials, handouts, and individual PowerPoint sets are available on the
Bree Collaborative website: http://www.hta.hca.wa.gov/bree_schedule.html
Background and History of AIM:
AIM was the predecessor collaborative. Leah Hole-Curry, former Health Care Authority program
manager who worked on the AIM efforts, presented. Members provided handout of the outcome
reports (http://www.hta.hca.wa.gov/documents/aim_report-2009-08.pdf and
http://www.hta.hca.wa.gov/documents/aim_phase_final_report.pdf).
 AIM product proved a huge success for L&I in terms of improving quality and reducing costs.
 However, AIM did not achieve a statewide solution as envisioned.
 Nonetheless, a few members on the Bree members were also members of the AIM, and they
stated that the collaborative provided real value, which led to the creation of the Bree.
 AIM provides good lessons learned and foundation for Bree.
Expectations of Legislation:
See: http://www.hta.hca.wa.gov/documents/Bree_Outcomes_McGill.pptx
Jason McGill, Governor’s Health Policy Advisor, provided an overview of the legislation and the
expectations for the group.
 Bree is named after Dr. Robert Bree, who was a member of AIM and recently passed away. He was
a leading evidence-based radiologist at the UW/Harborview. Bree Members who knew him spoke
fondly and honored his memory.
 Jason outlined that: The collaborative shall identify health care services for which there are
substantial variation in practice patterns or high utilization trends in Washington state, without
producing better care outcomes for patients...
 And that: By July 2012 develop at least one impactful state-wide solution to a significant health
care problem in our state.
 Summary of criteria to consider in selecting topic to include substantial variation, high utilization
and inefficiency in care delivery, patient safety issues, and whether there are proven
means/strategies to address this topic (leverage other opportunities) to scale-up efforts that are
working well.
 Once Bree selects a topic, it should form a clinical committee, consider other efforts, and provide
an opportunity for public comment.
 Solutions and strategies should include, but are not limited to:
 Identifying goals for appropriate utilization and variation;
 peer-to-peer consultation or second opinions
 provider feedback reports
 use of patient decision aids
 incentives for appropriate use of health care services
 centers of excellence or other qualification standards
 quality improvement systems
 service utilization and outcomes reporting
 research to improve care quality and outcomes
 Then the full Bree committee should vote on the proposed solutions and strategies.
 The recommendations go to the administrator of the Health Care Authority to thoroughly review
and decide whether they should be applied to all state purchased health care programs (Medicaid,
PEBB, L&I, & DOC).
 This is not a coverage decision for private payers.
 Following the Administrators review, Bree should report to the Legislature and the Governor.
Funding:
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Steve discussed potential of HRSA grant, contributions by member organizations, and perhaps
forming a grant sub-committee.
Group proposed that we return to this issue once we have more detail about estimates (see follow
up item to raise $60,000: http://www.hta.hca.wa.gov/documents/bree_budget_proposal.pdf)
We discussed possibility for federal SHAP grant funds as initial startup.
Discussion – Potential First Areas of Study:
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Steve led discussion about survey results regarding what topics to discuss for possible selection
(see: http://www.hta.hca.wa.gov/documents/bree_survey_summary.docx).
Steve proposed Bree goals could include: e.g. one quick win, one longer term project.
1. C-Sections and Convenience Inductions:
o Dr. Thompson presented (see: http://www.hta.hca.wa.gov/documents/CSection_Rates_Thompson.ppt)
o Group discussed that the goal is hard to define, so would take some work, but generally
agreed that it was a ripe to select because of the high variation and that so much work has
already been done (Medicaid, Joint Commission, Perinatal Collaborative, WSHA).
o Greg Marchand, Boeing, thought this was a good topic, noting that it seemed like Bree
could bring this one to the finish line.
o Dr. Haftel, noted the success at Franciscan, using hard stops and believes that feedback
report would work, although some will argue the details.
2. Cardiology procedures:
o Dr. Gifford proposed this topic and discussed that the use of appropriate guidelines could
reduce variation.
o Dr. Gifford thought this was a good topic because the guidelines and tools already exist,
they just need adoption.
3. Preventable Hospital Readmissions:
o Dr. Thompson presented (see:
http://www.hta.hca.wa.gov/documents/Readmissions_Thompson.ppt )
o Dr. Thompson discussed that we do not have a useful DRG code; that CMS has already
taken action on 30-day readmits.
o Discussion about excluding certain conditions like cancer due to the necessary inpatient
follow up treatment for chemo. Discussion about mandating checklists, Dr. Flum’s COAP
tool. Jodi commented that there are delivery system elements that do not yet exist that
could be quick wins. Susie mentioned the STAR program at WSHA.
4. Management of Early Stage Prostate Cancer:
o Dr. Rose presented (see: http://www.hta.hca.wa.gov/documents/bree_prostate_cancer_er.docx)Group
o Discussed that shared decision making could be an effective tool. Communication key.
o Dartmouth Atlas decision aides already out there.
o Some barriers exist because of specialty practice (urology/oncology). Very expensive.
5. Complex Back Surgeries:
o Dr. Franklin presented (see: http://www.hta.hca.wa.gov/documents/Spinal_Fusion_Franklin.pptx)
o Discussed the difficulty with low back fusion surgery for pain patients. Outcomes have not
been good, and there’s high variation across state and country.
o Regence and Premera have in place a guideline review, and do not cover uncomplicated
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pain cases.
State purchasers must cover (with conditions) due to Health Technology Assessment
program state decision.
More evidence is needed to show effectiveness/ineffectiveness.
Dr. Franklin suggests a letter of support to Dr. Flum’s Spine-SCOAP program, but
emphasizes that prospective comparative effectiveness research must be done, not just a
registry.
Dr. Mecklenburg notes that Virginia Mason has applied an evidence based approach,
working with employers, noting that this was a strong interest of employers to avoid
unnecessary surgery and return employees to health and function fast (and save money
and time-loss).
Dr. Freed noted the variance and the high tendency for opioid pain medication posttreatment.
Group discussion, generally supporting SCOAP approach.
Pick First Topic & Determine Process
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Group discussed process for selection. Reviewed legislation and requirements.
Group confirmed that a quick win would be good.
Steve asked for the employer representative perspectives:
o Kerry Schafer, King County, emphasized that employers want high impact solutions for
employees to provide high quality and reduce costs.
o Kerry notes that King County is looking very carefully at pricing and outcome depending on
provider – notes high value in Group Health because of its integrated system – “integrates
quality”
o Kerry also notes that KC has a health economist on staff now.
o Jay Tihinen, Costco, supports all efforts, but notes that Costco has an expensive plan, and
would like to make employees better consumers and wants providers to engage
employee/patients with decision aide tools.
o Jay notes the high costs for Costco are maternity and muscular-skeleton
o Also notes that Costco does not want to present access to care barriers for employees.
o Jay mentioned Safeway’s approach to reference pricing, and that Costco is looking in to it.
o Tom Fritz, Inland, emphasizes measurement for efficiency, cost and outcomes as a key
outcome/strategy on any topic selected. He says “let’s go!”
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Group agrees to put topics to a vote.
The members approved the process.
Group thought the method employed to present possible topics worked well; and in fact enjoyed
the discussion, and feel sufficiently informed about voting.
Group decided to give each member two votes (because Bree intends to take up more than one
topic as it goes forward, but would like to prioritize accordingly).
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Group voted:
VOTE OUTCOMES:
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5.
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c-section/maternity care: 15 votes
Readmissions: 10 votes
Complex back/low back: 7 votes
Cardiology: 7 votes
Prostate Cancer: 1 vote
Group decided to prioritize 1. C-section/maternity care and 2. Readmissions
Group decided to form sub-groups for 1. C-section/maternity care and 2. Readmissions.
State Budget Brief
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Jason McGill, Governor’s Health Policy Advisor, presented: Considering the very difficult budget
deficit caused by the great recession and further turmoil this summer in Europe and lack of timely
action in Washington DC that almost resulted in a government shut-down, Washington State sales
tax revenue has dropped precipitously by $1.5 billion worse than just expected in March.
Possible cuts include Basic Health (35,000 people), Disability LifeLine, Long Term Care, etc. these
are awful; up until now, we’ve been able to avoid major cuts to safety net programs.
Jason emphasized the time is now, that we have no more time for pilot projects.
He emphasized that health care has the best and brightest – it’s the not problem that we don’t
know what to do – it’s that we can’t seem to scale-up good ideas in a swift and timely manner.
We’re wasting billions (trillions) in health care. Health care inflation growth is why we can’t fully
fund education. Governor’s priority is an affordable health system for our state citizens, business,
to remain competitive, locally and globally.
Lawsuits are tying our hands and not effective solutions.
The Bree Collaborative is in a unique position to make a real positive impact – to scale-up good
ideas – the Governor is optimistic and challenges the Bree to lead the way!
Organizational Items
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By-Laws – Discussed briefly, handed out a copy (see: http://www.hta.hca.wa.gov/documents/bree_bylaws.doc)
Did not vote on by-laws.
Vice Chair & Steering Committee – Steve mentioned his plan to consider a vice-chair and perhaps
an organizing committee. Members thought that was a good idea.
Next meeting – Members agreed to meet as needed, and schedule accordingly.
Adjourned 5 p.m.