From Concept to Contracting: How One Purchaser Uses Bree Best Practice Recommendations to Achieve the Triple Aim

Replacing a joint—especially a knee or hip—is a procedure that millions of Americans need each year. It can give people a mobility and freedom from pain they haven’t enjoyed in years. It’s also a procedure that lends itself to a lot of variation. If best practices aren’t followed, it can lead to complications and hospital readmission. That’s not good for the patient—and it’s not good for the health care system.

Using the Total Joint Replacement bundled payment recommendations from the Dr. Robert Bree Collaborative, the Washington State Health Care Authority has contracted with Virginia Mason Medical Center as a “center of excellence” for hip and knee joint replacements for public employees enrolled in the Uniform Medical Plan. Bundled payments mean we will pay one sum for the entire episode care, from the pre-surgical visit to discharge from the hospital.

Bundled payments are a key strategy for HCA’s move toward value-based purchasing under our Value-based Road Map. As the largest purchaser of health care in the state—we purchase care for 1 in 3 non-Medicare Washingtonians through our Public Employees Benefits Board (PEBB) Program and Apple Health (Medicaid)—we are a first mover in innovative payment practices that improve health care quality and health outcomes for residents, and reduce costs.

A key partner every step of the way is the Bree. As stated in its founding legislation, the Bree’s job each year is to choose up to three health care services for which there is substantial variation in practice or high utilization trends in Washington and, for each topic, identify strategies to improve quality and reduce unnecessary variation. When the Legislature created the Bree, it intended health care stakeholders to implement the recommendations, and HCA has taken that charge seriously, incorporating them in our purchasing strategies.

In addition to the total joint replacement recommendation, we have included in our new Accountable Care Program (ACP) contracts that are offered through PEBB, the requirement the contracted delivery systems follow Bree care transformation recommendations. More than 10,000 public employees and their families enrolled in one of our two new accountable care networks (a group of medical organizations collectively committed to serving patients through a coordinated care network). Puget Sound High Value Network and University of Washington’s Medicine Accountable Care Network now serve public employees in the five-county Puget Sound region, and we are expanding to more counties around the state for 2017.

Via direct contracts with the HCA, these networks have agreed to assume clinical, financial (including pharmacy), and patient experience responsibility for defined populations of public employees. Reimbursement is based on performance across financial guarantees and quality measures taken from the Washington Statewide Common Measure set.

Our goal is that by 2021, 90 percent of state-financed health care will be linked to quality and value, as defined by the federal Health Care Payment Learning & Action Network Alternative Payment Model framework. It’s an ambitious goal, but we can’t afford not to move away from fee-for-service. We get what we pay for right now. By linking payment to quality and value, we will fundamentally change the way care is provided in Washington.

The Bree is a critical part of health care transformation in Washington. And we want other purchasers to join us in this innovative work. To learn more and for resources, including public copies of the ACP contracts for use by other purchasers, go to www.hca.wa.gov/hw/Pages/acp_multipurchaser.aspx.

Health plans and providers can sign up for future procurement notices at: https://fortress.wa.gov/ga/webs

Dan Lessler, MD
Chief Medical Officer
Health Care Authority