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Western ACO Public Reporting

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

EASTERN RIO BLANCO COUNTY HEALTH SERVICE DISTRICT

N

GRAND RIVER HOSPITAL DISTRICT

N

GUNNISON VALLEY FAMILY PHYSICIANS

N

GUNNISON VALLEY HOSPITAL

N

HOPEWEST

N

LAKE FORK HEALTH SERVICES DISTRICT

N

LINDA M. PETERSON, MD, PLLC

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

 

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
Curtis Anna Member 1 ACO Participant Representative MOAB VALLEY HEALTHCARE INC
Riddell Pat Member 1 ACO Participant Representative WESTERN COLORADO IPA
Santilli Rob Member 1 ACO Participant Representative GUNNISON VALLEY HOSPITAL
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

 

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 2019, $0
  • First Agreement Period
    • Performance Year 2020, $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