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Dr. Robert Bree Collaborative Meeting Minutes - DRAFT Wednesday, November 15, 2017 | 12:30-4:30

Puget Sound Regional Council 1101 Western Ave | Seattle, WA 98104

Members Present Phil Colmenares, MD, (for John Espinola, MD,

MPH), Premera Blue Cross Gary Franklin, MD, Labor and Industries Stuart Freed, MD, Confluence Health Jennifer Graves, RN, MS, WSHA Rick Goss,* MD, Harborview Medical Center Christopher Kodama, MD, MBA, MultiCare

Cooperative Robert Mecklenburg, MD, Virginia Mason

Medical Center Kim Moore, MD, Franciscan Health System Carl Olden, MD, Pacific Crest Family Medicine

Mary Kay O’Neill, MD, MBA, Partner, Mercer John Robinson, MD, SM, First Choice Health Terry Rogers, MD, Vice Chair Jeanne Rupert, DO, PhD, One Medical Kerry Schaefer, MS, King County Bruce Smith, MD, Regence Blue Shield Angie Sparks, MD, (for Paula Lozano, MD, MPH),

Kaiser Permanente Hugh Straley, MD, Chair Emily Transue, MD, MHA, (for Dan Lessler, MD,

MHA), Health Care Authority

Members Absent Susie Dade, MS, Washington Health Alliance Rick Ludwig, MD, Providence Health

Accountable Care

Greg Marchand, the Boeing Company Lani Spencer, RN, Amerigroup Shawn West, MD, Edmonds Family Medicine

Staff and GuestsLuAnn Chen, MD, Community Health Plan of

Washington Lori Cohen, Community Health Plan of

Washington Charissa Fotinos, MD, Health Care Authority Thomas Gallagher, MD, University of

Washington Medical Center Leah Hole-Marshall, JD, Labor and Industries Lynne Korte,* Department of Social & Health

Services, DSHS Pat Kulpa,* MD, MBA, Regence BlueShield

Ethan Norris, Alvarez & Marsal Healthcare Steve Overman, MD MPH, KenSci, Inc. Kristoffer Rhoads, PhD, University of

Washington Dennis Utley, MD, Confluence Health Kelly Veit, MPH, Foundation for Health Care

Quality Ginny Weir, Bree Collaborative Emily Wittenhagen, Bree Collaborative

* By phone/web conference Agenda and all meeting materials are posted on the Bree Collaborative’s website, here, under 2017, November 15th materials.

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CHAIR REPORT & APPROVAL OF SEPTEMBER 27TH, 2017 MEETING MINUTES Hugh Straley, MD, Chair, opened the meeting and all present introduced themselves. Dr. Straley welcomed new Bree member Angie Sparks, MD of Kaiser Permanente, and announced Susan Birch’s appointment as the new director for the Washington State Health Care Authority.

Motion: Approve the September 27th, 2017 Meeting Minutes. Outcome: Passed with unanimous support.

FINAL ADOPTION: OPIOID USE DISORDER Charissa Fotinos, MD, Health Care Authority went over the final Opioid Use Disorder Report and public comments received. The workgroup found comments to be on point, covering mindfulness of cultural appropriateness, Naloxone best practices, the role of the correctional system, rural health settings, and syringe exchange programs. Dr. Fotinos reviewed the final report, covering focus areas access to evidence-based treatment, referral information, and integrated behavioral and physical health to support whole-person care, as well as the goal of a no-wrong-door approach, the “doors” that exist in the current system, incorporating shared-decision making into options for treatment, reducing stigma and modifying language (avoiding “addict,” “dirty”, etc), supporting whole-person care, and medication-assisted treatment. Members discussed burden on primary care providers, modeling incentives for higher reimbursement, the buprenorphine waiver, and the availability for ongoing training programs (one being the Providers’ Clinical Support System), continuing to address pain, and avenues for implementing the recommendations and tracking those implementations.

Motion: Adopt Opioid Use Disorder Treatment Recommendations Outcome: Passed with unanimous support.

FINAL ADOPTION: TOTAL KNEE AND TOTAL HIP REPLACEMENT RE-REVIEW Robert Mecklenburg, MD, Virginia Mason Medical Center and Kerry Schaefer, MS, King County presented the re-review of the Total Knee and Total Hip Bundle and Warranty, covering the central goal of reducing unsafe and inappropriate surgery, the design of the recommendations for repurposing into contracts, and cost savings to the consumer. They also reviewed public comments, including minor changes, the removal of the World Health Organization global guidelines, language in the introduction encouraging small and rural practices to adapt the bundle to their needs, and previously endorsed changes, including post-op plans to support patients without care partners, failure rate thresholds for implants, and the process for addressing patients post-op whose recovery is not going according to plan. There were no changes to the metrics or warranty. Members expressed curiosity for how many surgeries are done currently using the bundle recommendations and if there’s anything the group can do to expand implementation. Members also discussed pain treatment following surgery, the bundle’s opioid recommendations that are in alignment with the other Bree opioid work, and the ongoing volume standard debate.

Motion: Adopt Total Knee and Total Hip Replacement Bundle and Warranty Outcome: Passed with unanimous support.

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TOPIC UPDATE: HYSTERECTOMY Jeanne Rupert, DO, PhD, One Medical presented an update on the Hysterectomy Report and Recommendations, covering the lead-up to a decision to have a hysterectomy, use of shared decision making and transparency in divulging the implications of hysterectomy and its alternatives, uterine sparing procedures, the decision tree algorithm inspired by an ACOG decision tree, encouragement of support for female employees, and the wish to certify the patient decision aid.

Motion: Adopt Hysterectomy Recommendations for dissemination for public comment. Outcome: Passed with unanimous support.

HEALTH CARE AUTHORITY: UPDATE ON OPIOID PRESCRIBING POLICY Emily Transue, MD, Health Care Authority presented on recent metrics and other findings concerning opioid prescribing and the Medicaid Opioid Prescribing Policy that went into effect on November 1, 2017, with the same policy applying to the Uniform Medical Plan (UMP) going into effect on January 2, 2018. This policy is aimed at reducing unnecessary exposure to opioids, reducing unused pills, ensuring safe transitions/best practices for chronic users, minimizing administrative burdens on providers, and encouraging adherence to guidelines while being cognizant of needs for exceptions. There are further materials on the HCA website here. PLANNING FOR 2018 Ginny Weir, MPH, Bree Collaborative reviewed the new/ongoing topics for 2018: LGBT Health Care, Collaborative Care for Chronic Pain, Suicide Prevention, Lumbar Fusion Bundle Re-Review, continued Opioid Prescribing, and endorsement of the WSHA/COAP Blood Use work. The LGBT Health Care group will be meeting January 15, 2018 (date subject to change), chaired by Dan Lessler, MD, Health Care Authority. The Collaborative Care for Chronic Pain group plans to convene in January 2018, chaired by Leah Hole-Marshall, JD, Labor and Industries. The Suicide Prevention group plans to convene in February 2018, chaired by Dr. Straley. The Re-Review Lumbar Fusion Bundle group plans to convene in January 2018, chaired by Dr. Mecklenburg and Ms. Schaefer. Ms. Weir also mentioned keeping in mind to explore what we can do to support broader efforts to implement value-based payment statewide in 2018, including supporting Accountable Communities of Health and the Health Care Authority’s adoption. COMMUNICATION AND RESOLUTION PROGRAM Thomas Gallagher, MD, University of Washington Medical Center presented on the Communication and Resolution (CRP) program in Washington State, now housed at the Foundation for Health Care Quality through the Washington Patient Safety Program and supported by the University of Washington. Dr. Gallagher covered the current state, wherein many patients who have undergone a medical error typically expect a more robust resolution from the provider/system than they receive. He spoke to the benefits of the CRP response, which include bringing resolution to both patients/families through proactive communication and to the provider with a care for the caregiver approach. He then gave some examples of the proven success of CRP, spoke to the emergence of CRP as a nationwide best practice, went over the process of CRP certification, and forecast the path forward in this work. One way the Bree Collaborative can contribute to this effort is by helping reduce the unwanted variation in how CRP programs are implemented.

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FINAL ADOPTION: ALZHEIMER’S DISEASE AND OTHER DEMENTIAS Kristoffer Rhoads, PhD, University of Washington Memory and Brain Wellness Center presented the Alzheimer’s and Other Dementias Report and Recommendations, covering a few recent “11th hour” changes made to the document, including the addition of resources on hearing loss, ongoing care and actions associated with stakeholder support, addressing the need for increased support and higher levels of care, preparing for potential hospitalization, screening for delirium risk prior to surgery, and the addition of acknowledgement for the association between hearing loss and dementia. Members discussed the role of the caregiver (i.e., the “hidden second patient”) and the importance of extending attention to their needs, as well as preventing unnecessary surgeries, and preventing other risks including falls. Members also discussed whether the correlation of hearing loss and dementia had enough of an evidence base to warrant inclusion in the report.

Motion: Adopt Hysterectomy Recommendations for dissemination for public comment. Outcome: Passed with a majority support; one dissent.

TOPIC UPDATE: AMDG OPIOID PRESCRIBING GUIDELINES IMPLEMENTATION Gary Franklin, MD, MPH, Washington State Department of Labor and Industries gave an update on the work of the AMDG Opioid Prescribing Guidelines workgroup, covering the Patient and Provider Fact Sheets, the opioid prescribing metrics, the newest iteration of the dental guidelines, the dental conferences coming up on January 8th and 9th (venues TBD), and new work kicking off an update to the 2015 AMDG guidelines for the perioperative opioid prescribing guidelines. The group discussed the perioperative opioid prescribing guidelines and an open invitation to join the mini-workgroup working on this, working with PBMs (Pharmacy Benefit Managers). GOOD OF THE ORDER/OPPORTUNITY FOR PUBLIC COMMENT Dr. Straley and Ms. Weir thanked all for attending and asked for public comments and final comments. The meeting was adjourned. Next Bree Collaborative Meeting:

January 24, 2017 | 12:30 - 4:30 Puget Sound Regional Council