Bree Collaborative Meeting
November 30, 2012
Members Present
Gary Franklin, MD, WA State Labor and Industries
Joe Gifford, MD, Providence Health & Services
Rick Goss, MD, Harborview Medical Center
Mary Gregg, MD, Swedish Medical Center
Anthony Haftel, MD, Franciscan Health Systems
Theresa Helle (for Greg Marchand), The Boeing
Company
Steve Hill, Bree Collaborative Chair
Beth Johnson, Regence Blue Shield*
Robert Mecklenburg, MD, Virginia Mason Medical
Center
Absent
Roki Chauhan, MD, Premera Blue Cross
Susie Dade, Puget Sound Health Alliance
Stuart Freed, MD, Wenatchee Valley Medical Center
Tom Fritz, Inland Northwest Health Services
Staff/Guest
Bill Alkire, Alkire & Associates*
David Arterburn, Group Health Cooperative
Molly Beinfeld, Informed Medical Decisions
Foundation (IMDF)
Kathryn Bergh, FHCQ
Chris Bryson, MD, COAP Medical Director
Jim Cannon, Providence Health & Services
Vergil Cabasco, WSHA
Maureen Collins, CareCore*
Anne Doherty Renz, Group Health Cooperative
Sharon Eloranta, MD, Qualis Health
Marcie Frost, WA Department of Retirement Systems
Leah Hole-Curry, WA State Labor and Industries
Camille Johnson, Virginia Mason Medical Center
Alice Marshall, FHCQ
Mary Kay O’Neill, MD, CIGNA
Robyn Phillips-Madson, DO, MPH, Pacific NW
University of Health Sciences*
John Robinson, MD, First Choice Health
Terry Rogers, MD, Foundation for Health Care
Quality (FHCQ)
Kerry Schaefer, King County
Jeff Thompson, MD, WA Health Care Authority
Peter Valenzuela, MD, PeaceHealth
Carl Olden, MD, Pacific Crest Family Medicine
Eric Rose, MD, Fremont Family Medical
Bruce Smith, MD, Group Health Cooperative
Jay Tihinen, Costco
Jason McGill, Governor’s Office
Csaba Mera, MD, Regence Blue Shield
Karen Merrikin, Group Health Cooperative
Josh Morse, HCA
Benjamin Moulton, IMDF
Tiffany Nelson, Group Health Cooperative
Bob Perna, WSMA
Rachel Quinn, Bree Collaborative
Julie Riley, IMDF*
Kristin Sitcov, FHCQ
Diana Stilwell, IMDF*
Carin Upstill, IMDF*
Richard Wexler, IMDF*
Mara Zabari, WSHA
* By phone/web conference
Agenda and all meeting materials are posted on the Bree Collaborative’s website, here, under the November 30th
meeting.
WELCOME
Steve Hill, Bree Collaborative chair, welcomed the group and called the meeting to order.
CHAIR REPORT & APPROVAL OF 10/1 BREE MEETING MINUTES
Mr. Hill briefly summarized several recent events that featured the work of the Collaborative. On November 29,
Mr. Hill and Rachel Quinn, Bree Collaborative Project Manager, testified at a hearing of the Washington State
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Senate Health & Long Term Care Committee. Mr. Hill said that the hearing went very well. The annual meeting of
the Washington State Obstetrical Association was also held on November 30; during the morning session
Collaborative member Dr. Carl Olden presented the Collaborative’s obstetrics report, and Governor Gregoire
discussed the Collaborative’s work in her speech at the event.
Mr. Hill mentioned that he will meet with Governor-Elect Jay Inslee soon and plans to tell him about the Bree;
several members of the Governor-Elect’s transition team are already very familiar with and enthusiastic about the
Collaborative’s work.
Collaborative members approved the minutes for the October 1st meeting.
Motion: To approve the minutes for the October 1st meeting with no changes.
Outcome: The motion was unanimously approved.
BREE COLLABORATIVE BYLAWS
Mr. Hill gave a presentation about the Collaborative bylaws. The group provided feedback on draft bylaws at the
last meeting, in October, and received an updated draft prior to this meeting.
The group briefly discussed section 2.3.9, relating to the use of outside committees. A member asked if the group
should have the right to vote on the decision to appoint an outside committee and recommend other
requirements for outside committees to adhere to as appropriate. The proposed language was to say that the
Collaborative “may elect by a majority vote of appointees to use committees”, and representatives from WSHA
and WSMA said that they were comfortable with that language. Another member said that provisions 6.2.1, 6.2.2,
and 6.2.3 should also apply to outside committees that are used by the Collaborative.
Motion: To approve the following amendments to section 2.3.9 of the draft bylaws:
1) Insert the words “by a majority vote of appointees” after “The Collaborative may elect…”
2) Amend the final sentence to include provisions 6.2.1, 6.2.2, and 6.2.3.
Outcome: The motion was unanimously approved.
Members also had the following comments:
 In section 3.3.3, we should change the word final to draft since products will not be finalized until they are
considered by the Collaborative. Mr. Hill said that this change would be made.
 Regarding section 3.3.2, the group should aspire to achieve consensus rather than a majority vote.
 Regarding section 5.1.6, it has been a problem to get materials in advance of the meeting. Rachel said that
she will strive to post all materials one week in advance of meetings.
 Regarding section 3.3.3, the group should consider whether the timeline for public comment is realistic.
Motion: To adopt the revised bylaws.
Outcome: The motion was unanimously approved.
Rachel asked the group about the best way to disseminate meeting materials. Members said that she should
email out the link to the HCA website when materials are posted rather than emailing the materials to members.
TOPIC UPDATES/ACTION ITEMS
Rachel presented an update on the obstetrics, readmissions, and spine/low back pain topic areas.
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Obstetrics (OB): Rachel reviewed recent successes in this area, including the announcement of the HCA
Administrator on 10/24 that the OB report recommendations will be adopted by state purchased programs.
Rachel asked the group to comment on strategies for targeting employers, measuring “reach”, and revisiting the
OB report in the future.
Members had the following comments:

Obstetrics outcomes like NTSV rates are already being posted at the hospital level on the WSHA and HCA
websites.

We should ask health plans to endorse the report while we have momentum. Mr. Hill agreed and said that
Collaborative staff would follow up by email with a plan.

The CMMI grant is integrated with a lot of these activities, so if we get that grant then we can work towards
developing an ACO design.

We could target employers through alliances, but those reach a limited number of employers.

We should return to purchasers including employer trusts when we have a more complete product with an
implementation plan.

Many small and mid-size employers don’t feel like they have any clout with health plans and will take
whatever the plan is offering them.

What is missing from this conversation is the collection of obstetrics data in a standardized way in which
every hospital participates. The Bree Collaborative recently endorsed all hospitals join a spine registry,
because transparency at the hospital level is the only way to get where we want in terms of quality
improvement. But the Bree Collaborative has stopped short by not making the same recommendation for all
hospitals to join an obstetrics registry, which will produce consistent, reliable, clinical information about
obstetric services. The Bree Collaborative is not being consistent, and should not back off from this issue.
This is an opportunity to do something that will pay off for everyone.

The Perinatal Collaborative is currently issuing a provider survey about changes in OB quality measures, and
those findings will be made available to the Collaborative in January.

We should consider what questions we’re trying to answer before adding to the data collection burden.

A health services researcher at the University of Washington may be able to get funding from the Robert
Wood Johnson Foundation for an evaluation.
Potentially Avoidable Readmissions (PAR): Rachel reviewed the progress of the PAR workgroup since the last
meeting and proposed the following action items (recommendations from the PAR workgroup):
1) Send letter to Qualis and WSHA asking them to publish 30-day all-cause readmission data, semi-publicly.
2) Endorse “concept” of the WSHA tool kit, but wait to endorse components or entire tool kit until pilot results
are known. For example, send letters to pilot communities & other stakeholders recognizing the work of
WSHA and its partners.
Mara Zabari, WSHA, handed out copies of the draft tool kit and presented a brief project summary.
The group discussed the first proposed action item. One member asked for Qualis and WSHA to weigh in on the
action item. A representative from Qualis said that most of this data is already publicly available in Qualis’ joint
report with WSHA. There is a process laid out in the CMS regulations for getting permission from hospitals to
publish other data; Qualis has done that several times in the past few years, and no hospitals have ever declined.
Members also had the following comments and questions:

Medicaid and Medicare data tell different stories about Washington’s rank relative to other states.
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
While publicly reporting CMS data should not be a problem, including the CHARS data could be confusing; the
CHARS data is not risk-adjusted.

CHARS data can be risk-adjusted. Other members raised concerns about being able to know whether CMS
and CHARS data are adjusted using the same models.

What is the timeframe for combining Medicaid, Medicare, and CHARS data? Rachel said that the PAR
workgroup has not determined a timeframe. Several members commented on the potential for complications
due to lags in data availability.

The PAR workgroup is still trying to figure out the minimum dataset that would provide the necessary
impetus for process improvement.
Mr. Hill encouraged the PAR subgroup to engage Qualis and WSHA to work out more of these issues and then
return to the full group with a more developed proposal.
The group moved on to the second proposed action item, to endorse the “concept” of the WSHA tool kit.
Members had the following comments and questions:

The language of the proposal should be strengthened to emphasize the importance of process measures.

It is also important to know how hospitals capture data about those process measures.

Is the tool kit based on nationally recognized standards? Can the Bree Collaborative recommend that health
plans and hospitals use the “communication and follow-up triage table”? Mara said that is based on IHI
materials that have been modified.

It is important to remember that the tool kit is a work in process; reducing readmissions is a system-level
change that requires will, ideas, and execution–the tool kit provides the ideas, but not how to implement.

The spirit of try, test, and adjust is valuable, so long as you do not do harm along the way.

Can existing care coordinators and social workers in hospitals be used to test components of the tool kit?
Several members and Mr. Hill said that the PAR workgroup’s proposal needed to be fleshed out with more specific
action items and metrics before the Collaborative could vote on it. Mr. Hill said that the Collaborative needs to
consider the degree to which it would like subgroups to come to the group with interim action items versus
developing a complete report before bringing it back to the group.
Accountable Payment Model (APM) Subgroup: Rachel summarized the direction agreed upon at the APM
subgroup’s first meeting. One of the APM subgroup members said that the overriding idea is that the
readmissions problem is hard to fix in a proscriptive way, and therefore the best approach is to change the
incentives and payment models; bundling payments for a “clean” procedure is a first step. A Collaborative
member asked whether the APM subgroup had considered payment reduction or no payment strategies for
readmissions (like Medicare’s current payment reduction program for pneumonia, heart failure and acute
myocardial infarction).
Spine/Low Back Pain: Rachel reviewed the initial focus agreed upon at the first meeting of the spine/low back
pain workgroup. Collaborative members said that the group should focus on the transition to chronic back pain
and that it is important to identify red flags.
PCI CARDIOLOGY UPDATE & ADOPTION OF CARDIOLOGY REPORT – FUTURE CARDIOLOGY
TOPICS/IDEAS
Mr. Hill said that a cardiology report is being drafted to summarize the work of the Collaborative and COAP in the
cardiology topic area. A completed draft should be available for review and adoption at the next meeting.
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Dr. Chris Bryson, COAP Medical Director, presented a summary of COAP’s work related to the appropriate use of
percutaneous cardiac interventions (PCI) in non-acute patients. Since the last Collaborative meeting, COAP has 1)
developed a plan for improving the submission of PCI data, 2) asked hospitals to allow their data to be public,
and 3) provided hospitals with pilot reports of what public reporting would look like. Some hospitals were
resistant to making data public because they did not see the relevance, questioned the definition of appropriate
use, or other reasons; most have agreed to publicly report but some have not. Kristen Sitcov, COAP Program
Director, gave a tour of the content currently available on the website and the template for the unblinded reports.
Members had the following comments and questions:

Which hospitals have not given permission? Dr. Bryson said he could not give out that information. But it may
be obvious from the reports, because hospitals that do not want their data public will be missing from the list.
COAP will continue education efforts to encourage participation.

If we collectively say that this is good data and these are good measures, then we can continue to move
hospitals in the right direction.

The reports should really emphasize non-responders: suggestions included having “giant holes” for nonresponders and listing non-responder hospitals as refusing to participate.

There is an opportunity for this group to make recommendations about how to publish data to highlight nonresponders.
Rachel introduced the draft report and said that the missing piece is a discussion of what the Collaborative wants
to recommend to the HCA about its application to state purchasing programs. Members had the follow ideas:

Purchasers should not purchase from hospitals that do not contribute data

Require an action plan for hospitals that have poor performance

Develop a center of excellence

Require in the contract for all providers to provide data to COAP

Not pay for something that does not meet appropriate use criteria
Mr. Hill asked the group to review the draft report before the next meeting. He also reminded the group that any
proposals must be endorsed by the HCA Administrator as a condition of the anti-trust protections provided to the
Collaborative. A member commented that when the Collaborative writes the consensus statement, it can
emphasize that we are asking to see facility-level data, not patient data.
Dr. Bryson gave a presentation about its phase of care mortality analysis (POCMA) efforts and suggested some
ways the Collaborative could support this effort: recognize participation, promote incentives for participation, or
establish a requirement based on mortality data. Dr. Bryson said that POCMA data would not be publicly
available. Members had the following comments: findings from Michigan may not apply to Washington; it is
important for the Collaborative to think about this type of audit approach because we will never be able to
capture all of the episodes that we would like; just saying that this is an important issue and work should
continue would be helpful.
PATIENT DECISION AIDS PRESENTATION
Staff from the Informed Medical Decisions Foundation (IMDF) gave a presentation about their work in shared
decision-making, including a pilot project at Group Health Cooperative in hip/knee patient decision aids (PpDAs)
and other demonstration sites.
The following topics were discussed during the question and answer period following the presentation:
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
Cost of implementation for providers: IMDF staff said that cost is still being worked out, but funding may be
available from the state or federal governments. Washington State’s CMMI grant application includes funding
for web-based training, but the HCA doesn’t know the unit cost or how to integrate it into electronic medical
records.

Potential benefits of pDAs: The CMMI grant, if awarded, would provide a unique opportunity to test whether
pDAs lead to reduced liability, premiums, and utilization rates.

Impact on length of visit: During a pilot program of pDAs at Group Health, the length of time spent with
patients did not increase; patients came to appointments with a higher level of knowledge.

Variation in physician uptake: A member asked whether all providers should be included in shared decision-
making initiatives given varying levels of skill and interest. IMDF staff said that patient surveys could be used
to assess provider performance.

Making complex information accessible: A member asked how pDAs can convey complex information such as
odds ratios to patients. IMDF staff said that there is a lot of literature available on this topic and it is possible
to teach patients numbers while avoiding concepts such as confidence intervals.

Distribution of pDAs: A member asked why less than 50% of eligible patients received pDAs in the Group
Health pilot. IMDF staff said that providers sometimes forget to give pDAs to patients. Group Health staff said
that they gradually increased pDA delivery rates through quality improvement efforts related to pre-visit work
and asking primary care providers (PCPs) to order pDAs at the time of referral.

Potential conflict of interest for providers: A member asked when it was appropriate for the specialist to be
involved versus the PCP. Group Health staff said that they started with specialists to increase buy-in, but the
level of engagement varied across groups and they are still wrestling with questions about which provider is
the most appropriate to deliver decision aids.

Provider incentives: A member said that there is no reward in many systems for providers to use pDAs, which
may cause revenue and payment to get out of alignment if pDA use reduces provider incomes.

Cost structure: IMDF staff said that there is usually an annual licensing fee and a per unit cost.

Benefit design to increase pDA use: IMDF staff said that benefit design strategies have been used in some
demonstration projects. A member said that some large employers are currently using this strategy.

Potential role for Bree: A member asked whether the Collaborative would consider inviting liability carriers
and attorneys to discuss this further, and Mr. Hill said that he would need a more detailed proposal.
GOOD OF THE ORDER
Mr. Hill announced that Beth Johnson and Joe Gifford were both appointed by the Governor to the Collaborative
and that the next Collaborative meeting will be rescheduled to avoid Friday afternoon since that is a bad time for
many members. Morning meetings will also be avoided. Mr. Hill also said that both Consumer Reports and
Leapfrog have independently released hospital safety scores, and he is trying to get copies of both reports for
distribution and comparison at the next meeting.
Mr. Hill opened up the meeting for any other comments. No comments were made.
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