Bree Collaborative’s Draft Recommendations and Warranty for Heart Surgery

August 12, 2015

Date:      August 12, 2015

To:        Hospital CFOs, Quality Leaders and Government Affairs Staff

From:    Claudia Sanders, SVP Policy Development

Staff Contact:  Ian Corbridge,, 206-216-2514

Subject:   Bree Collaborative’s Draft Recommendations and Warranty for Heart Surgery

To inform you about the Dr. Robert Bree Collaborative Collaborative) draft report on heart surgery and the companion warranty, and encourage you to comment on the reports (via the Collaborative’s online survey here.

Recommendations from the Collaborative will be considered in health care purchasing by the Health Care Authority (HCA) as well as private payers. The recommendations in the draft reports could impact state and private payment for facilities performing or planning to perform Coronary Artery Bypass Grafts (CABG).

WSHA Recommendations
WSHA fully supports efforts to improve patient safety and recovery while reducing costs associated with heart surgery. Potentially unnecessary overuse of heart surgery is a serious issue. While the recommendations may improve care across the state, we have some concerns with how the recommendations are calibrated.

The Collaborative is a private group of clinician leaders from payers and providers who have been appointed by the Governor and charged with recommending care improvements. The Collaborative is circulating draft reports for feedback. It will review comments and may revise the recommendations prior to adoption. Comments on the reports are due Friday, August 21, 2015. We encourage you to submit your own comments directly or contact us with your feedback. (Submit comments here.) Please send WSHA a copy of any comments you submit; we will also submit comments directly. 

The draft reports outline four evidence-based cycles to improve the treatment of heart disease and patient outcomes associated with heart surgery. The cycles are intended to ensure appropriate need for surgery, quality surgery and appropriate aftercare follow up. The intent is that if providers and payers follow the cycles, the surgeries provided will be appropriate and effective. In addition, the reports recommend providers give a warranty, up to 90 days, for certain complications from the surgery.

WSHA’s review raises the following issues that may merit comment and additional consideration:

Mandatory reporting systems. WSHA fully supports transparency and the collection and reporting of quality metrics. The Collaborative report recommends the Washington State Foundation’s COAP as the sole quality reporting system. Our policy position on such matters is that the Collaborative and other similar groups should identify measures that need to be reported to a registry, but that providers should be allowed to choose where they decide to report. We encourage the Collaborative to identify meaningful measures and make a recommendation that hospitals should report these to a registry for quality and benchmarking purposes.

Access to care.  We fully support thorough pre- and postoperative evaluations, but are concerned about how the recommendations could impact access, especially in rural areas. We would encourage development of a system where the non-surgical portions of the bundle (i.e., cycles 1, 2, and 4) may be offered at facilities close to where a patient lives, rather than only through the facility performing the surgery. If care is centered only at one site, this could place an additional burden on rural residents who may be required to make multiple trips over an extended period to a facility outside of their community. This could drive up health care costs for patients and have unintended consequences.

Providing access to health services close to where patients live is important, and local community hospitals have a place in delivering care even if they don’t perform the surgery. We recommend a balanced approach with options for non-surgical portions of the bundle to be performed outside of the hospital/system performing the surgery. Under the current bundle, it appears as if a local facility would have to make arrangements with a referral facility to provide these services, instead of being able to offer them independently.

Barriers to care. Patient engagement and support from a “care partner” are important components to a healthy recovery. However, the report’s requirement that a patient “must designate a personal care partner” may be too strong and could impede access to care simply because a patient lives alone or does not have a care partner who can travel to the hospital. This could be especially burdensome for patients in rural communities or low income patients without family able to support them. We recommend allowing more options, by encouraging a care partner while acknowledging individual patient circumstances.


The Bree recommendations, released July 22, 2015 include a four-cycle model for conducting heart surgery:

  1. Documentation of disability despite explicit non-surgical care;
  2. Meeting fitness requirements for patients prior to surgery;
  3. Adherence of standards for best practice surgery; and
  4. Implementation of a structured plan to rapidly return patients to function.

Each of the four cycles contains specific inclusion or exclusion criteria, screening tools, volume requirements and other standards aimed at improving patient outcomes and uniformity of heart surgery. Many of the recommendations of the Collaborative generally align with evidence-based surgical recommendations and the work already underway in Washington State to improve the discharge process and patient return-to-function process. Access a link to the report’s evidence table here.

Bree Process
The Collaborative views the public comment period as a way to solicit broad stakeholder input and appreciates the public’s interest and feedback on this work. The Accountable Payment Models workgroup will meet soon to review the comments and make revisions to the bundle and warranty, which will then be shared with the full Collaborative. The Collaborative will vote to approve or not approve the bundle. If approved, the Collaborative will forward the bundle and warranty to HCA. HCA can then elect to use the bundle and warranty in its procurement and contracting for Medicaid and state employees.

Background and References: 
Click here for more information on the Bree Collaborative.


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