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.