For the past year, our Accountable Payment Models workgroup has been reviewing evidence, hearing from community members, and revising our Lumbar Fusion Bundled Payment Model and Warranty. At our recent Bree Collaborative January meeting, members voted to adopt the bundle and warranty. Our goal in this revision was to respond to changes in the evidence but also to make our model more usable for our health care community. Big changes include expanding the scope beyond a single level of fusion and expanding surgical site to include both in- and out-patient. We also added language to be used for contracting as well as detailed procedural and complication codes. During this process we also revised our evidence table, bringing our number of reviewed articles to 123 citations.

We are very grateful for our workgroup members but also for the many community members and professional associations who offered constructive changes so that we were able to create a pragmatic, evidence-based bundled payment model and warranty.

Other notable changes include:

  • – Cycle I
    • – Adding additional optional patient reported outcomes measures to our previous requirement of PROMIS-10 and Oswestry Disability Index: Roland-Morris Disability Scale, EuroQual-5 Dimensions (EQ-5D), Short Form 36 (SF-36), Therapeutic Associates Outcome Score, and/or a similarly peer-reviewed and validated patient-reported outcome
    • – Adding to documentation of imaging findings confirming lumbar instability “Previous decompressive surgery requiring significant facetectomies for foraminal decompression that are expected to create instability in the spinal segment
    • – Replacing the requirement that a physiatrist lead the collaborative team, although this is still preferred, and adding a requirement that a consultation with a physiatrist be obtained to validate that optimal non-surgical care has occurred and that surgery is indicated.
    • – Adding more specificity to the trial of non-surgical measures prior to surgery (i.e., Risk stratification with the STarT Back tool or similar to inform treatment plan, active physical therapy aimed specifically at patients with lumbar segmental instability, with a program of spinal stabilization and hip mobilization).
    • – Moving shared decision making to the first cycle.



  • – Cycle III
    • – Changing the standards for the surgical team and facility to the minimum number of lumbar fusions being 30 per primary or first assist surgeon and 60 per – facility in the previous 12 months.
    • – Replacing the requirement that surgery be performed in an inpatient facility with the requirement that the facility have sufficient staffing and access to resources to address potential complications.
    • – Adding requirements to follow the 2018 Bree Collaborative Prescribing Opioids for Postoperative Pain – Supplemental Guidance.


  • – Cycle IV
    • – Adding assessment of the home environment for safety and adequate support (e.g. architectural barriers, availability of assistive devices, availability of care companion)
    • – Adding measurement of patient reported functional outcomes with standard instruments at three months and if possible at 12 months as specified above using the same tools used for initial assessment.
    • – Adding continuing nicotine avoidance measures for at least three months following surgery.


  • – Quality Standards
    • – Adding examples for measurements of evidence-based surgery (e.g., blood count for measures to reduce blood loss and need for transfusion).
    • – Adding the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey.


  • – Warranty
    • – Replacing infection involving implant with deep incisional surgical site infection that may involve implant at 90 days.
    • – Removing death from warranty.
    • – Adding that “the facility performing the surgery must have an agreement with a hospital to manage complications following surgery” and that “the facility will provide information and instructions to the patient to seek treatment at that designated hospital.”


  • – Adding an Appendix C to assist with the contracting process.


  • – Adding an Appendix E with procedural and complication codes.


Read our Bundle and Warranty!

Read our Evidence Table!


Ginny Weir, MPH
Director, Bree Collaborative