The Bree Collaborative is committed to working with all of our members and partners to improve health care quality, outcomes, and affordability in our state. This is what the legislature asked us to do when we were founded in 2011 and what we have continued to do when we looked at how babies are born, how to improve end-of-life care, and how to improve specific types of surgery.

Right now, most surgeries are paid for with what we call fee-for-service, where physicians and other providers are paid for the number of surgeries they provide. Both Washington State and our Federal Government have said that they want to move away from this type of relationship and toward paying for the quality or value of procedures. Sometimes this is called moving to paying for value from volume. A bundled payment is one tool that groups all the care you would receive during a surgery, like a knee replacement, into one payment. The idea is that this promotes patient safety, increases the value of health care, and ensures that all the care you receive is coordinated around you. If we are paying doctors to talk to one another, chances are they will indeed talk to one another. One of my favorite ways of explaining bundled payments is with this cartoon:

Our group has taken this idea and developed bundled payment models for three different types of surgeries: elective total knee and total hip replacement, elective lumbar fusion, and elective coronary artery bypass surgery. We call these surgeries episodes of care so we can include the care you receive before the surgery, the surgery itself, and the rehabilitative care you receive after the surgery in one chunk of money.

Starting with Knees and Hips

We started by looking at elective total knee and total hip replacements. Many people receive hip and knee replacements in our state, but unfortunately the type of care that people get is often different between different hospitals and the number of people who have to go back to the hospital for things like infections that could have been avoided is high. You can see for yourself the differences in the number of people who are admitted back to the hospital after a knee or hip replacement here:

We organized our bundle into four phases:

– Making sure that the patient needs the surgery after a trial of what we call conservative therapy – this usually includes things like physical therapy. While a knee replacement can be great and help people move around with much less pain, we want to be sure this is the best way to help people live the life they want because there are risks with any surgery.
– Making sure the patient is fit for surgery – including things like reducing the risk of complications from having a higher weight, and controlling blood sugar in diabetic patients.
– Best practices for the surgery itself.
– Supported recovery from the surgery and helping patients return to their normal lives.

We also included a requirement to collect quality of care data and a warranty that makes it so hospitals won’t be paid for readmissions for complications, like infections, that should have been avoided. All of these bundled payment models are created by a diverse group of people including physicians, employers who purchase health care for their employees, those from insurance companies, and researchers who look at health care quality. These bundles are small steps toward better surgical care and we will continue to make these better when new evidence is available.

National Work

The Federal Government is interested in bundled payments too. They have recently announced a proposed program called the Comprehensive Care for Joint Replacement Payment Model. If the program is rolled out, hospitals in the Puget Sound area are going to be providing bundled payments for Medicare beneficiaries who are getting knee or hip replacements. Find more information here:

Public Comments

The public comment process is a valuable time for our workgroup to see how the community responds to our suggestions. Many of you have asked us about how these bundles will effect access to care in rural areas, how we include the patient responsibility for health in the bundle and warranty, difficulties of data collection, and how it might be much more expensive for facilities to provide services they may not have been providing earlier such as a health coach. These are important questions and we hope to work with our community to make sure there are not any unintended consequences from these models. Our organization cannot recommend how much to pay for services, but we encourage the bundle to be able to pay enough to cover essential services like a health coach.

We created the bundles to make sure that surgery is the best option for a patient, to improve the way patients experience surgery, to improve health after the surgery, and to help make these surgeries more affordable. We also want to account for the judgement of physicians and so are very clear that if patient safety is threatened, whether through highly disabling osteoarthritis or heart failure, the surgical team should perform the surgery as needed.

Coronary Artery Bypass Graft Surgery

We are setting a best practice guideline for a total episode of care and safety is our highest priority. We appreciate the opportunity to work with our community to improve all of our bundles and most recently the coronary artery bypass surgical bundle.

This workgroup met for eight months to adapt our previous models to coronary artery bypass graft surgery. We are proud of this work and thankful for the many workgroup members who dedicated their time and energy to making care safer and more patient-centered. This Bundle and Warranty will be up for adoption at our September 16th Bree Collaborative meeting. If you are interested in learning more about this model we encourage you to attend or call into the meeting, information here:

You can learn more about our other work here:

Ginny Weir, MPH
Program Director, Bree Collaborative