Bree Collaborative Meeting

October 1, 2012

Members Present

6

Roki Chauhan, MD, Premera Blue Cross

Susie Dade, Puget Sound Health Alliance

Gary Franklin, MD, WA State Labor and Industries

Stuart Freed, MD, Wenatchee Valley Medical Center

Tom Fritz, Inland Northwest Health Services

Rick Goss, MD, Harborview Medical Center

Mary Gregg, MD, Swedish Medical Center

Anthony Haftel, MD, Franciscan Health Systems

Steve Hill, Bree Collaborative Chair

Beth Johnson, Regence Blue Shield

Jodi Joyce, RN, Legacy Health

Robert Mecklenburg, MD, Virginia Mason Medical Center

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

David Grossman (for Bruce Smith, MD), Group Health Cooperative

Jeff Thompson, MD, WA Health Care Authority

Peter Valenzuela, MD, PeaceHealth

6

Absent

6

Greg Marchand, The Boeing Company

Carl Olden, MD, Pacific Crest Family Medicine

Eric Rose, MD, Fremont Family Medical

Jay Tihinen, Costco

6

Staff/Guests

6

Bill Alkire, Alkire & Associates

Kathryn Bergh, FHCQ

Jim Cannon, Providence Health & Services

Maureen Collins**

Vergil Cabasco, WSHA

Pat Ford

Joe Gifford, MD, Providence Health & Services

Ellen Kauffman, MD, FHCQ

Vickie Kolios-Morris, FHCQ

Denny Maher**

Alice Marshall, FHCQ

Jason McGill, Governor’s Office

Bob Perna, WSMA

Rachel Quinn, Bree Collaborative

Larry Schechter, Providence Health & Services**

Neal Shonnard, MD, Spine SCOAP Medical Director

Tracey Tyrrell, Eli Lilly

6

* By phone

** By internet

Agenda and all meeting materials are posted on the Collaborative’s website, here, under the October 1st meeting.

CALL TO ORDER

Steve Hill, Collaborative chair, called the meeting to order.

CHAIR REPORT

Mr. Hill gave a quick Collaborative member update. The process of filling the position vacated by Joe Gifford, formerly at Regence and now at Providence Health & Services, is still being finalized; in the meantime, Beth Johnson will represent Regence. Jodi Joyce has accepted a new position and Chicago, so she will be stepping down from the Collaborative. The Governor’s Office will work with the Washington State Hospital Association to identify a replacement.

Collaborative members approved the meeting minutes for the August 2nd meeting.

Motion: To approve the meeting minutes for the August 2nd meeting with one change: strike the words “not surgeons” from the end of the first paragraph on page 2.

Outcome: The motion was unanimously approved.

Rachel Quinn, Collaborative project manager, presented an update on the four topic areas: Readmissions, Spine/Low back pain, Cardiology, and Obstetrics.

·  Readmissions: The Readmissions workgroup has adopted a work plan and will hold its third meeting in mid-October to start prioritizing care transition strategies and reviewing the report outline. The Accountable Payment Model subgroup is currently being formed on the basis of nominations from Collaborative members and other stakeholder groups. Most of the people who have been asked to serve have said yes. Thanks to the Puget Sound Health Alliance, a webinar has been scheduled with payment reform experts Harold Miller and Francois de Brantes on October 12th.

·  Spine/Low Back Pain: At the August meeting, the Collaborative approved a motion to form a workgroup to develop evidence-based recommendations on appropriate management of acute low back pain (under 3 months). This group is being finalized, and the first meeting will be scheduled for the end of October/beginning of November. Collaborative members recommended including a family physician and osteopathic physician; it was noted that Dr. John Robinson currently represents the former group. Rachel asked members to send her names of osteopathic physicians to be considered for the workgroup (The full list of subgroup nominees is available here.)

·  Cardiology: Work is continuing to leverage the work of the COAP program to build transparency around appropriate use of percutaneous coronary interventions (PCIs). COAP staff are currently working with hospitals to provide technical assistance and tools to reduce the amount of insufficient information about PCI use, with the goal of meeting with every hospital before the end of 2012. An updated report based on 4th quarter 2012 data will be provided to the Collaborative and hospitals (target date: April 15, 2013) and then posted on the public section of the COAP website (target date: May 1, 2013). Collaborative members were very positive about this progress and plan, which was described as “precedent-setting” and a model for the rest of the nation. Other comments included:

o  The presentation should not say PCI is inappropriate for elective procedures (slide 6).

o  Questioned why hospitals will have the option to not be identified, which led to a broader conversation about a perceived increase in momentum for transparency in this state. Several members support labeling hospitals that decline to be identified as “refusal to comply” to encourage reporting.

o  Suggestion that a final step should be to publish appropriate use criteria, although it was pointed out that those are already available from the American College of Cardiology.

Mr. Hill recommended writing a short, formal report about this progress and plan and submitting it to the Washington State Health Care Authority (HCA) for comment and adoption. Several members acknowledged the burden of gathering data, but the general consensus was that it was worth the investment and that purchasers will be very supportive.

·  Obstetrics: The OB Report was sent to the HCA administrator on August 21st, and the outcome of that review should be available in the next few weeks. The WA Department of Health (DOH) sent the report to all hospital CEOs and the WA Perinatal Collaborative and the goal is to reach out to OB chiefs, quality heads, hospital board chains, and media outlets in the next few weeks. Mr. Hill encouraged all of the members to disseminate the report through their own networks. Some Collaborative members said hospitals may be more motivated to adopt the recommendations due to recent policy shifts; CMS determined a few weeks ago that elective deliveries prior to 39 weeks will now be subject to mandatory reporting and posted on Hospital Compare, and JCAHO standards may become mandatory. However, one member suggested thinking about ways to offer bonuses through payment mechanisms rather than relying solely upon mandates.

WA State CMMI Proposal

Jason McGill, Governor’s Office, gave a presentation about the Washington State health care innovation grant application submitted to CMS/CMMI on September 23rd. Washington State applied for a $34 million grant to implement new payment methods and develop quality and utilization metrics and evaluation criteria. The State proposed starting with developing new payment methodologies in the areas of obstetrics/deliveries (using the Bree Collaborative as a forum) and managing chronic conditions (using the Puget Sound Health Alliance as a forum) since work has already been initiated in both areas. Mr. McGill noted the large amount of support provided by organizations and companies across the state, citing the fact that the proposal received over 80 letters of support. A decision is expected in December, and work would begin immediately if the grant is awarded. If the state does not get the grant, it may be awarded $2 million for further design of the current proposal. One Collaborative member commented that standardizing claims data and definitions of evidence-based medicine may be necessary to successfully implement the grant, if awarded.

New Topic Selection Discussion

Rachel Quinn gave a brief presentation and led a discussion about the accomplishments of the Collaborative in its first year and future plans. OB Implementation, which is moderately resource-intensive, is expected to be finished by the end of 2012, while readmissions and spine/low back pain (both of which have high resource intensity) are predicted to conclude in March 2013. Cardiology work is expected to be completed in April 2013, but has low resource intensity. The outcome of the CMMI grant application and upcoming changes in government leadership may affect Collaborative resources, but the current resources (1 FTE) are at maximum capacity. Therefore, Rachel recommended waiting until the November or January meeting to consider the selection of an additional topic or topics.

Some Collaborative members expressed concerns about whether the time frames presented were realistic, particularly for the payment reform subgroup, and included sufficient time for implementation and evaluation activities. One Collaborative member suggested that the Collaborative could try to use purchasing power to help align incentives and move forward faster. Another Collaborative member recommended looking at the amount of money being spent on different topics to help guide topic selection. Other comments included: hold new topic selection discussion soon so when more resources are available the Collaborative is ready to move on to the next topic; and the Collaborative should be careful not to start new things if that means failing to sustain past efforts.

The following topic areas were recommended for future consideration:

·  Radiology

·  Chemotherapy (the Collaborative can build on chemotherapy recommendations outlined in Choosing Wisely reports)

·  Payment Reform (independent of a specific health topic, as in the Readmissions subgroup)

·  Oncology

None of the Collaborative members voiced disagreement with the proposal to hold off on new topic selection until the November 30th or January Collaborative meetings.

Rachel asked what type of information Collaborative members need in advance of a broader strategic planning discussion. Collaborative members and guests had the following comments: the outcome of the CMMI grant will make a big difference; it would be helpful to have an idea of the size of potential savings and/or scope and identify areas where the Collaborative can have the most impact; the Collaborative should consider data collection recommendations carefully because if increased without reducing it in other areas, data collection could become burdensome; oncology is one of the biggest spends in this state and variation is phenomenal; based on the experience of the OB topic, believe we could be effective in an emotional area like cancer; and the CMMI grant includes money for decision aids, so maybe that should be a part of future efforts.

The group had a brief discussion about the future of the Collaborative given there will be a gubernatorial change in January, and whether it would be in a more secure position as a non-governmental organization (NGO). Mr. Hill said that he thinks the Collaborative will keep moving ahead regardless of the outcome of the election since both gubernatorial candidates seem very committed to health care quality efforts and health care reform. Representative Eileen Cody and Senator Karen Keiser are both very committed to the Collaborative as well. Mr. Hill also said that as a program HCA, the Collaborative benefits from the anti-trust laws, which may be lost if the Collaborative became an NGO.

Mr. Hill closed the discussion by asking people to comment more on their reflections about the past year. One member said OB was a good starting point because it was a very focal, doable topic; another member stated that the Readmissions workgroup needs some re-focusing. Mr. Hill said a lot of re-framing initially needed to be done by the OB subgroup and that it was a challenge to keep the work of the Collaborative aligned with other groups already working on OB quality improvement efforts. That said, the Collaborative in the future should consider who else is already working on a topic before beginning work in that area.

Bree collaborative Structure & Bylaws

Mr. Hill presented the draft bylaws for the Collaborative, which he would like the Collaborative to aim to adopt at the next Collaborative meeting on November 30th. The draft bylaws are based upon the legislation enacted in 2011 (HB 1311) that created the Collaborative, with some additions made at the discretion of Mr. Hill and Collaborative staff. The bylaws have the following six sections:

1)  Purpose and Mandate – No comments or proposed changes.

2)  Membership and Terms

a.  Comments: Some concern about ceding authority for member appointments to the Governor because that may politicize the Collaborative, but others were not worried about it becoming partisan and said Governor appointments made membership more special; members did not know that Dr. Terry Rogers had been appointed Vice-Chair, but nobody voiced opposition.

b.  Proposed Changes

  1. Add a description of the appointment process for the steering committee.
  2. Add a public health representative to the Collaborative.
  3. Add language clarifying that if the Collaborative elects to use committees from another organization, that committee must adhere to workgroup rules laid out in Collaborative bylaws.

3)  Responsibilities

a.  Proposed Change: Add language specifying that the Collaborative will post final products on the Health Care Authority website at least one week prior to consideration by the Collaborative.

4)  Reporting and Review Requirements – No comments or proposed changes.

5)  Meetings and Meeting Materials

a.  Comments: Want to ensure that committees have control over their own processes and meetings; processes for public review and comment are very important; concerned that the Collaborative will receive complaints about not having open committee meetings.

b.  Proposed Changes

  1. Add language specifying the process for public review and comment.
  2. Add a patient representative to the list of individuals who are allowed to attend clinical committee, advisory group, and work group meetings.

·  Collaborative members were split on whether this should be in the bylaws or at the discretion of the committee chairs, and whether a consumer advocate or patient navigator would be more helpful.

6)  Other – No comments or proposed changes.

Motion: The Collaborative chair and staff will incorporate the feedback received at this meeting and present a final draft of the bylaws at the November 30th meeting.

Outcome: The motion was unanimously approved.

Spine COAP Registry Proposal Neil Shonnard, MD, Spine SCOAP Medical Director

Dr. Neil Shonnard, Medical Director of Spine SCOAP, gave a presentation about the Spine SCOAP’s proposal to the Collaborative. Spine SCOAP requests the Collaborative establish participation in Spine SCOAP as a community standard, starting with hospitals performing spine surgery. Dr. Shonnard raised the proposal at the Collaborative meeting in August, and agreed to present a formal proposal at this meeting.