Western ACO Shared Savings Program Public Reporting
Performance Year 2021
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
Organizational Information
| 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 |
| Coombs | Jim | Member | 1 | ACO Participant Representative | GRAND RIVER HOSPITAL DISTRICT |
| Lokey | Bryce | Member | 1 | ACO Participant Representative | CEDAR POINT HEALTH LLC |
| Wigington | Yvonne | Member | 1 | ACO Participant Representative | MONTROSE MEMORIAL HOSPITAL, INC |
| Mink | Barry | 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. Kevin Fitzgerald
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 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
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
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 |
| Phillips | Cory | Member | 1 | ACO Participant Representative | CEDAR POINT HEALTH LLC |
| Gerson | Elaine | Member | 1 | ACO Participant Representative | ASPEN VALLEY HOSPITAL DISTRICT |
| Coombs | Jim | Member | 1 | ACO Participant Representative | GRAND RIVER HOSPITAL DISTRICT |
| Lokey | Bryce | Member | 1 | ACO Participant Representative | CEDAR POINT HEALTH LLC |
| Wigington | Yvonne | Member | 1 | ACO Participant Representative | MONTROSE MEMORIAL HOSPITAL, INC |
| Mink | Barry | 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. Kevin Fitzgerald
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:
- Third Agreement Period
- Performance Year 2021, $0
- Second Agreement Period
- Performance Year 2020, $0
- First Agreement Period
- Performance Year 2019, $0
Shared Savings Distribution:
- Third Agreement Period N/A
- Second Agreement Period N/A
- First Agreement Period N/A
Quality Performance Results:
MIPS CQMs
Please note, the Quality ID #: 370 Depression Remission at 12 months quality measure is not included in public reporting due to low sample size.
| ACO Quality Measure Number | Measure Name | Rate | ACO Mean | |
| 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control2 | 16.83
|
12.46 | |
| 134 | Preventative Care and Screening: Screening for Depression and Follow-up Plan | 66.24
|
74.38 | |
| 236 | Controlling High Blood Pressure | 70.67
` |
74.87 | |
| 318 | Falls: Screening for Future Fall Risk | 51.4
|
87.03 | |
| 110 | Preventative Care and Screening: Influenza Immunization | 71.49
|
80.52 | |
| 226 | Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention | 62.9
|
80.97 | |
| 113 | Colorectal Cancer Screening | 53.21
|
73.63 | |
| 112 | Breast Cancer Screening | 64.09
|
75.11 | |
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 74.61
|
84.24 | |
| 479 | Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups2 | 0.1322 | 0.1540 | |
| MCC1 | All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)2 | 28.75 | 33.99 | |
| CAHPS-1 | Getting Timely Care, Appointments, and Information | 79.24 | 84.67 | |
| CAHPS-2 | How Well Providers Communicate | 92.77 | 93.56 | |
| CAHPS-3 | Patient’s Rating of Provider | 90.51 | 92.19 | |
| CAHPS-4 | Access to Specialists | 73.05 | 78.80 | |
| CAHPS-5 | Health Promotion and Education | 58.9 | 61.61 | |
| CAHPS-6 | Shared Decision Making | 60.28 | 60.89 | |
| CAHPS-7 | Health Status and Functional Status | 72.15 | 71.78 | |
| CAHPS-8 | Care Coordination | 26.76 | 85.66 | |
| CAHPS-9 | Courteous and Helpful Office Staff | 90.34 | 91.88 | |
| CAHPS-11 | Stewardship of Patient Resources | 84.05 | 24.71 | |
For previous years’ Financial and Quality Performance Results, please visit: data.cms.gov