Bree Collaborative’s Draft Surgery Bundle Recommendations

August 12, 2014

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 Surgery Bundle Recommendations for Lumbar Fusion


Purpose:  To inform you about  the Dr. Robert Bree Collaborative draft report on Lumbar Fusion Surgery Bundle and the companion report on Spinal Fusion Warranty. We encourage you to comment on the reports, after reading them along with the issues discussed in this bulletin.

Applicability/Scope: Recommendations from the Bree 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 payment on services purchased by the state for facilities performing or planning to perform lumbar fusions.

WSHA Recommendations: WSHA fully supports efforts to improve patient safety and reduce costs associated with lumbar fusions. The potentially unnecessary overuse of lumbar fusion surgery is a serious issue. The Bree Collaborative developed the report recommendations using a workgroup of experts including purchasers, quality improvement organizations, medical administrators, a Chief Financial Officer, a health plan, and surgeons. 

The Bree 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 15, 2014. However, at WSHA’s request, the Bree Collaborative will continue to accept comments until Tuesday, August 19, 2014. We encourage you to submit your own comments directly. Comments can be submitted here. Please send us a copy of any comments you submit. WSHA will also be submitting comments directly. 

The draft reports outline four evidence-based cycles to improve the treatment of back pain and patient outcomes associated with lumbar fusions. The cycles are intended to ensure appropriate need for surgery, quality surgery, and appropriate after-care follow-up. The intent is that if providers and payers follow the cycles, there will be better quality surgeries done when truly needed. In addition, the reports recommend a warranty, up to 90 days, for certain complications from the surgery. 

Some of the recommendations from the report could limit the number of services available in the state which can raise issues on access to care. At WSHA, we do not have a clear understanding of the volume of surgeries or where they are being performed. We are investigating whether we can use 2013 hospital discharge data (CHARS) to assess the volume of lumbar fusions and their geographic distribution. We will share the data when they are available. 

WSHA’s review raises the following issues that may merit comment and additional consideration:  
Volume standard for surgery.  The report recommends a minimum volume standard (twenty) for spine surgeons to perform spinal fusions. While volume can be an important component to assuring quality, the relationship between volume and patient outcomes for spinal fusions is less clear. Based on an initial pull of hospital discharge data for 2013, approximately 150 providers and 10 out of 43 hospitals would NOT have met the volume requirement. We have engaged with Bree Collaborative representatives on this topic and would prefer to use a quality standard as opposed to a volume standard. A volume standard may not prevent poor quality and may have the unintended impact of encouraging some low volume providers to do more cases. 

Access to care.  WSHA is concerned about access, especially in rural areas. Some hospitals may NOT be able to meet all four cycles of the bundle. The non-surgical portion of the bundle (i.e., cycles 1, 2, and 4) requires detailed patient assessments, physical therapy, and provider interactions. It could place an additional burden on rural residents if care can only be provided at the hospital/system performing the fusion. Rural residents could be required to make multiple trips over a four-month period to a facility outside of their community.  This needs to be balanced with the other considerations on quality and outcomes. 

Physical therapy.  The report requires three months of ‘active physical therapy.’ We are investigating whether Medicaid and other plans typically pay for such services. 

Bundle tools.The bundle may include a proprietary screening tool, which could mean an additional cost on hospitals. WSHA is investigating if other non-proprietary tools are available. The bundle explicitly identifies some screening tools while simply noting that screening should take place in other areas of the report. Can additional clarity be provided in these instances around measure specifications, screening tools, and time frames?

Overview:  The Bree recommendations, released July 24, 2014, include a four-cycle model for conducting lumbar fusion 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 lumbar fusion surgery. Many of the recommendations of the Bree Collaborative generally align with evidence-based surgical recommendations and work already underway in Washington State to improve the discharge process and patient return to function process. A link to the report’s evidence table can be accessed here.

Bree Process: The Bree Collaborative views the public comment period as a way to solicit broad stakeholder input. It 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 Bree Collaborative. They will vote to approve or not approve the bundle. If approved, the Bree 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 ReferencesBack pain is a common medical problem affecting eight out of ten people at some point in their lives.[1] The majority of patients with back pain (about 90%) see improvement in pain and function within two months with minimal intervention.[2] There is broad consensus that lumbar fusion surgery is appropriate to mitigate emergent spinal instability from major trauma, tumor, infection, or congenital anomalies, however, its use and benefit in non-emergent situations is less clear. The number of patients undergoing lumbar fusion is increasing rapidly and disproportionately to other spine surgeries.[3] This being said, evidence demonstrates that “lumbar fusion surgery is associated with a substantial complication rate, is costly to patients and purchasers, and for many, is of uncertain benefit compared with non-surgical care.”[4]
The Bree Collaborative is a consortium of public and private health care stakeholders who “work together to improve quality, health outcomes, and cost effectiveness of care in Washington State.” The Bree Collaborative is making recommendations on lumbar fusions as it addresses health care issues where there is evidence of high variability in outcomes and cost.
For more information on the Bree Collaborative, click here.


[1] Premera Blue Cross. Medical policy: Lumbar fusion. Number 7.01.542. Effective date: April 8, 2013.
[2] Premera Blue Cross. Medical policy: Lumbar fusion. Number 7.01.542. Effective date: April 8, 2013.
[3] Dr. Robert Bree Collaborative. Draft report, Lumbar Fusion Surgery Bundle, July 24, 2014,
[4] Dr. Robert Bree Collaborative. Draft report, Lumbar Fusion Surgery Bundle, July 24, 2014,



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