Shared Savings Program Public Reporting Template and Instructions
Overview
This document provides Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (Shared Savings Program) with a public reporting template and instructions on how to complete the template. ACOs participating in the Shared Savings Program are required to publicly
report ACO organizational information and performance results on a designated webpage, per
42 CFR § 425.308.
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 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
Last Name |
Member
First Name |
Member
Title/Position |
Member’s Voting Power (Expressed as a percentage or number) | Membership Type | ACO Participant Legal Business Name and D/B/A, if applicable |
| Phillips | Cory | Member | 1 | ACO Participant Representative | CEDAR POINT HEALTH LLC |
| Gerson | Elaine | Member | 1 | ACO Participant Representative | ASPEN VALLEY HOSPITAL DISTRICT |
| Bertapelle | Andy | Member | 1 | ACO Participant Representative | GUNNISON VALLEY HOSPITAL |
| Coombs | Jim | Member | 1 | ACO Participant Representative | GRAND RIVER HOSPITAL DISTRICT |
| Lokey | Bryce | Member | 1 | ACO Participant Representative | CEDAR POINT HEALTH LLC |
| Riddell | Pat | Member | 1 | ACO Participant Representative | WESTERN COLORADO IPA |
| Wigington | Yvonne | Member | 1 | ACO Participant Representative | MONTROSE MEMORIAL HOSPITAL, INC |
| Luzmoor | Beth | Member | 1 | Medicare Beneficiary Representative | N/A |
| Wren | Kyle | Member | 1 | ACO Participant Representative | RANGELY HOSPITAL DISTRICT |
| Sellers | Liz | Member | 1 | ACO Participant Representative | EASTERN RIO BLANCO COUNTY HEALTH SERVICE DISTRICT |
| Lassaux | Marc | Member | 1 | Stakeholder Member | N/A |
| Belcher | Paula | Member | 1 | ACO Participant Representative | THE MEMORIAL HOSPITAL |
| Field | Jenny | Member | 1 | ACO Participant Representative | GUNNISON VALLEY HOSPITAL |
| Skillicorn | John | Member | 1 | ACO Participant Representative | COMMUNITY MEDICAL GROUP LLC |
| Amrich | Jason | Member | 1 | ACO Participant Representative | GUNNISON VALLEY HOSPITAL |
Key ACO Clinical and Administrative Leadership:
ACO Executive: Marnell Bradfield
Medical Director: Dr. Gregg Davis
Compliance Officer: Sharma Vaughn
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 | Cory Phillips, Chair |
| Medicare Council | Dr. Bryce Lokey |
| Executive Committee | Cory Philips, 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:
- Second Agreement Period
- Performance Year 2020, $0
- First Agreement Period
- Performance Year 2019, $0
Shared Savings Distribution:
- Second Agreement Period NA
- First Agreement Period NA
Quality Performance Results
2020 Quality Performance Results:
Please note, the ACO-40 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size. The Centers for Medicare & Medicaid Services (CMS) also waived the requirement for ACOs to field a CAHPS for ACOs survey for PY 2020 through the Physician Fee Schedule Final Rule for Calendar Year 2021. Additionally, CMS reverted ACO-8 Risk-Standardized, All Condition Readmission and ACO-38 Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions to pay-for-reporting, given the impact of the coronavirus disease 2019 (COVID-19) public health emergency (PHE) on these measures.
| ACO Quality Measure Number | Measure Name | Rate | ACO Mean | |
| ACO-43 [3] | Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality Indicator (PQI #91)) | 0.85 | 0.95 | |
| ACO-13 | Falls: Screening for Future Fall Risk | 68.16 | 84.97 | |
| ACO-14 | Preventive Care and Screening: Influenza Immunization | 76.09 | 76.03 | |
| ACO-17 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 69.70 | 81.67 | |
| ACO-18 | Preventive Care and Screening: Screening for Depression and Follow-up Plan | 68.31 | 71.46 | |
| ACO-19 | Colorectal Cancer Screening | 58.81 | 72.59 | |
| ACO-20 | Breast Cancer Screening | 65.78 | 74.05 | |
| ACO-42 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 78.23 | 83.37 | |
| ACO-27 | Diabetes Mellitus: Hemoglobin A1c Poor Control | 17.38 | 14.70 | |
| ACO-28 | Hypertension (HTN): Controlling High Blood Pressure | 69.37 | 72.87 | |
For Previous Years’ Financial and Quality Performance Results, Please Visit data.cms.gov