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Shared Savings Program Public Reporting Template

ACO Name and Location

Western Accountable Care Organization, LLC
715 Horizon Drive, Suite 485
Grand Junction, CO 81506

ACO Primary Contact

Marnell Bradfield
970-986-3679
Marnell.Bradfield@wha1.org

Organizational Information

ACO Participants:

ACO Participants ACO Participant in Joint Venture
ASPEN VALLEY HOSPITAL CLINICS, PLLC N
ASPEN VALLEY HOSPITAL DISTRICT N
CEDAR POINT HEALTH LLC N
COMMUNITY MEDICAL GROUP LLC N
EASTERN RIO BLANCO COUNTY HEALTH SERVICE DISTRICT N
GRAND RIVER HOSPITAL DISTRICT N
GUNNISON VALLEY FAMILY PHYSICIANS N
GUNNISON VALLEY HOSPITAL N
LAKE FORK HEALTH SERVICES DISTRICT N
LINDA M PETERSON, MD, PLLC N
MIDVALLEY FAMILY HEALTH PRACTICE PC N
MOAB VALLEY HEALTHCARE INC N
MONTROSE MEMORIAL HOSPITAL, INC N
MOUNTAIN MEDICAL CENTER LLC N
PAULA KADISON MD PC N
RANGELY HOSPITAL DISTRICT N
THE MEMORIAL HOSPITAL N

 

ACO Governing Body:

Member

First Name

 Member

Last Name

 Member

Title/Position

 Member’s Voting Power (Expressed as a percentage) Membership Type ACO Participant Legal Business Name, if applicable
Alyssa Franklin Member 1 ACO Participant Representative ASPEN VALLEY HOSPITAL CLINICS, PLLC
Elaine Gerson Member 1 ACO Participant Representative ASPEN VALLEY HOSPITAL DISTRICT
Jim Coombs Member 1 ACO Participant Representative GRAND RIVER HOSPITAL DISTRICT
Rhonda Parker Member 1 ACO Participant Representative MONTROSE MEMORIAL HOSPITAL, INC
Barry Mink Member 1 Medicare Beneficiary Representative N/A
Kyle Wren Member 1 ACO Participant Representative RANGELY HOSPITAL DISTRICT
Liz Sellers Member 1 ACO Participant Representative EASTERN RIO BLANCO COUNTY HEALTH SERVICE DISTRICT
Marc Lassaux Member 1 Stakeholder Member N/A
Paula Belcher Member 1 ACO Participant Representative THE MEMORIAL HOSPITAL

 

Key ACO Clinical and Administrative Leadership:

ACO Executive: Marnell Bradfield

Medical Director: Vacant, Currently Recruiting

Compliance Officer: Marnell Bradfield

Quality Assurance/Improvement Officer: Marnell Bradfield

 

Associated Committees and Committee Leadership:

Committee Name Committee Leader Name and Position
Compliance Committee Elaine Gerson, Chair
Finance & Audit Committee Vacant, currently recruiting new Chair
Medicare Council Dr. Bryce Lokey
Executive Committee Elaine Gerson, WACO Board Vice Chair

 

Types of ACO Participants, or Combinations of Participants, That Formed the ACO:

  • ACO professionals in a group practice arrangement
  • Hospital employing ACO professionals
  • Networks of individual practices of ACO professionals
  • Critical Access Hospital (CAH) billing under Method II
  • Rural Health Clinic (RHC)

 

Shared Savings and Losses

Amount of Shared Savings/Losses:

  • Fourth Agreement Period
    • Performance Year 2022, $0
  • Third Agreement Period
    • Performance Year 2021, $0
  • Second Agreement Period
    • Performance Year 2020, $0
  • First Agreement Period
    • Performance Year 2019, $0

Shared Savings Distribution:

  • Fourth Agreement Period
    • Performance Year 2022
    • Proportion invested in infrastructure: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A
  • Third Agreement Period
    • Performance Year 2021
    • Proportion invested in infrastructure: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A
  • Second Agreement Period
    • Performance Year 2020
    • Proportion invested in infrastructure: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A
  • First Agreement Period
    • Performance Year 2019
    • Proportion invested in infrastructure: N/A
    • Proportion invested in redesigned care processes/resources: N/A
    • Proportion of distribution to ACO participants: N/A

 

Quality Performance Results

2022 Quality Performance Results:

Quality performance results are based on CMS Web Interface

Measure # Measure Name Collection Type Rate ACO Mean
Quality ID# 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control [1] CMS Web Interface 6.27 10.71
Quality ID# 134 Preventative Care and Screening: Screening for Depression and Follow-up Plan CMS Web Interface 73.29 76.97
Quality ID# 236 Controlling High Blood Pressure CMS Web Interface 72.17 76.16
Quality ID# 318 Falls: Screening for Future Fall Risk CMS Web Interface 63.75 87.83
Quality ID# 110 Preventative Care and Screening: Influenza Immunization CMS Web Interface 71.61 77.34
Quality ID# 226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS Web Interface 80.95 79.27
Quality ID# 113 Colorectal Cancer Screening CMS Web Interface 68.06 75.32
Quality ID# 112 Breast Cancer Screening CMS Web Interface 77.60 78.07
Quality ID# 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS Web Interface 78.94 86.37
Quality ID# 370 Depression Remission at Twelve Months CMS Web Interface 16.33 16.03
Measure# 479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups [1] Administrative Claims 0.1432 0.1510
Measure# 484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions [1] Administrative Claims 23.09 30.97
CAHPS-1 Getting Timely Care, Appointments, and Information CAHPS for MIPS Survey 80.12 83.96
CAHPS-2 How Well Providers Communicate CAHPS for MIPS Survey 92.65 93.47
CAHPS-3 Patient’s Rating of Provider CAHPS for MIPS Survey 91.28 92.06
CAHPS-4 Access to Specialists CAHPS for MIPS Survey 74.08 77.00
CAHPS-5 Health Promotion and Education CAHPS for MIPS Survey 62.43 62.68
CAHPS-6 Shared Decision Making CAHPS for MIPS Survey 59.49 60.97
CAHPS-7 Health Status and Functional Status CAHPS for MIPS Survey 74.93 73.06
CAHPS-8 Care Coordination CAHPS for MIPS Survey 85.07 85.46
CAHPS-9 Courteous and Helpful Office Staff CAHPS for MIPS Survey 93.45 91.97
CAHPS-11 Stewardship of Patient Resources CAHPS for MIPS Survey 26.93 25.62

For previous years’ Financial and Quality Performance Results, please visit: data.cms.gov

Payment Rule Waivers

  • Skilled Nursing Facility (SNF) 3-Day Rule Waiver:
    • N/A
  • Waiver for Payment for Telehealth Services:
    • N/A

 

Fraud and Abuse Waivers

  • There are no Fraud and Abuse Waivers to disclose.