Mary Washington Health Alliance MSSP Enhanced (2022-Current)
ACO Name and Location
Mary Washington Health Alliance, LLC.
2300 Fall Hill Ave.
Suite 308A
Fredericksburg, Virginia 22401
ACO Primary Contact
|
Primary Contact Name
|
Travis Turner
|
|
Primary Contact Phone Number
|
(540) 741-1557
|
|
Primary Contact Email Address
|
travis.turner@mwhc.com
|
Organizational Information
ACO Participants:
| ACO Participants |
ACO Participant in Joint Venture |
| Access Eye |
N |
| Advanced Digestive Care, LLC |
N |
| Allergy Partners of Fredericksburg |
N |
| American Anesthesia Associates |
N |
| Aquia Family Medical Center |
N |
| Belmont Aesthetic and Reconstructive Plastic Surgery |
N |
| BetterMed Urgent Care |
N |
| Blue Nile Medical Center |
N |
| Brett Chicko DPM Family Foot and Ankle Center |
N |
| Cardiology Associates of Fredericksburg |
N |
| Carriage Hill Health and Rehab |
N |
| Centercare Family Practice, LLC |
N |
| Centercare Urgent Care |
N |
| Central Virginia Anesthesia Anesthesia Concepts |
N |
| Central Virginia Internal Medicine |
N |
| Central Virginia OBGYN Group |
N |
| Central Virginia Orthopedics & Sport Medicine |
N |
| Central Virginia Podiatry |
N |
| Central Virginia Sleep Center |
N |
| Chancellor Internal Medicine |
N |
| Colonial Internal Medicine Associates PC |
N |
| Commonwealth Internal Medicine |
N |
| Cornell J Shelton MD PLLC |
N |
| DHMR Clinics |
N |
| Diabetes and Thyroid Associates |
N |
| Elite Womens Health Inc |
N |
| ENT & Facial Plastic Surgery of Fredericksburg |
N |
| Fairfax Medical Clinic LLC |
N |
| Fall Hill Gastroenterology Associates |
N |
| Family Care of Fredericksburg |
N |
| Fredericksburg Anesthesia Services |
N |
| Fredericksburg Christian Health Center |
N |
| Fredericksburg Emergency Medical Alliance |
N |
| Fredericksburg Foot & Ankle Center |
N |
| Fredericksburg Nephrology Associates |
N |
| Fredericksburg Women's Health Associates |
N |
| Gaertner Psychiatric PC |
N |
| GAF Sedation |
N |
| Gastroenterology Associates of Fredericksburg |
N |
| Internal Medicine of Virginia PC |
N |
| Lee's Hill Family Physicians PC |
N |
| Mary Washington Cardiology |
N |
| Mary Washington Dermatology |
N |
| Mary Washington Endocrinology |
N |
| Mary Washington Eye Care Center |
N |
| Mary Washington Family and Internal Medicine |
N |
| Mary Washington Family Medicine |
N |
| Mary Washington Family Medicine and Pediatrics |
N |
| Mary Washington Family Medicine Orange |
N |
| Mary Washington General Surgery & Trauma |
N |
| Mary Washington General Surgery Lee’s Hill |
N |
| Mary Washington Hospitalist Services |
N |
| Mary Washington Neurology |
N |
| Mary Washington Neurosurgery |
N |
| Mary Washington Observation Unit |
N |
| Mary Washington Obstetrics and Gynecology |
N |
| Mary Washington Orthopedics |
N |
| Mary Washington Primary Care |
N |
| Mary Washington Radiation Oncology |
N |
| Mary Washington Rheumatology |
N |
| Mary Washington Sleep Medicine |
N |
| Mary Washington Spine and Rehabilitation Clinic |
N |
| Mary Washington Surgical Oncology |
N |
| Mary Washington Urgent Care |
N |
| Mary Washington Urology |
N |
| Mary Washington Virginia Cardiovascular and Thoracic Surgery |
N |
| Mary Washington Weight Loss Center |
N |
| McManus & Associates Internal Medicine |
N |
| Medical Imaging of Fredericksburg |
N |
| MediDoctors LLC dba Mary Washington Home Health & Hospice |
N |
| Meridian Independent Physician Group |
N |
| MetroHealth Internal Medicine PC |
N |
| Metropolitian Health Care Providers Inc |
N |
| New Beginnings ObGyn |
N |
| North Stafford Family Medical Center |
N |
| Northern Virginia Hematology & Oncology Associates |
N |
| NOVA Cardiovascular Care, LLC |
N |
| OBHG Hospitalist |
N |
| Optimum Care LLC |
N |
| Oracle Heart & Vascular LLC |
N |
| Orthopedic Specialty Clinic Ltd |
N |
| PACS at Ruther Glen |
N |
| Pathology Associates of Fredericksburg |
N |
| Plastic Surgery Services |
N |
| Polaris Heart and Vascular PLLC |
N |
| Prime Regenerative and Pain Management |
N |
| Psychiatric Care Inc |
N |
| Pulmonary Associates of Fredericksburg |
N |
| Radiation Oncology Specialists of Central Virginia |
N |
| Radiologic Associates of Fredericksburg |
N |
| Rapidan Medical Center Inc |
N |
| Rappahannock Family Healthcare Inc |
N |
| Rappahannock Women's Health Center Inc |
N |
| Serenite Medical & Spa |
N |
| Sieht |
N |
| Sleep Disorder Center of Fredericksburg |
N |
| Stafford Internal Medical Services |
N |
| Stafford Neurology |
N |
| The Center for Orthopedics |
N |
| The Dermatology Center |
N |
| Urology Associates of Fredericksburg |
N |
| Virginia Cardiovascular Consultants |
N |
| Virginia Center for Allergy & Asthma |
N |
| Virginia Dermatology and Skin Surgery Center |
N |
| Virginia Interventional and Vascular Associates |
N |
| Virginia Oncology Care, PC |
N |
| Virginia Urgent Care LLC dba NextCare Urgent Care |
N |
| Vista Eye |
N |
| WeCare Medical Associates |
N |
| William A Hamilton MD |
N |
| Womens Health and Surgery Center INC |
N |
Key ACO Clinical and Administrative Leadership:
ACO Governing Body:
|
|
Member's Last Name
|
Member's First Name
|
Member's Title/Position
|
Member's Voting Power |
Membership Type |
ACO Participant TIN Legal Business Name/DBA, if Applicable |
|
McManus
|
Patrick
|
MD,
Chairman/Voting Member
|
1
|
ACO Participant Representative
|
McManus & Associates Internal Medicine, PC
|
|
McDermott
|
Michael
|
MD, Vice Chair/Voting Member
|
1
|
ACO Participant Representative
|
Washington Hospital, Inc., Mary
|
|
Christopher
|
Newman
|
MD,
Secretary/Voting Member
|
1
|
ACO Participant Representative
|
Washington Hospital, Inc., Mary
|
|
Frazier
|
Jeffrey
|
MD,
Treasurer/Voting Member
|
1
|
ACO Participant Representative
|
Radiologic Associates of Fredericksburg, Ltd.
|
|
Vranian
|
Robert
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Virginia Cardiovascular Consultants, PC
|
|
Thott
|
Kurian
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Women’s Health and Surgery Center, Inc.
|
|
Szlyk
|
Gregory
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Urology Associates of Fredericksburg, PC
|
|
Amory
|
Charles
|
MD
|
0
|
Other – Community Physician
|
Chancellor Pediatrics
|
|
DeTrane
|
Frank
|
MD
|
1
|
ACO Participant Representative
|
Gastroenterology
Associates of Fredericksburg
|
|
Vacant
|
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
TBD
|
|
Sims
|
Adam
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Fredericksburg Emergency Medical Alliance, Inc.
|
ACO Executive: Travis Turner
Medical Director: Patrick McManus, MD
Compliance Officer: Lauren Blalock
Quality Assurance/Improvement Officer: Daniel Woodford, MD
Associated Committees and Committee Leadership:
|
Committee Name
|
Committee Leader Name and Position
|
|
Nominating Committee
Clinical Quality Committee
Finance & Contracting Committee
Membership & Operations Committee
Information Technology Committee
Communications & Education Committee
|
Dr. Kenneth McDowell- Chair
Dr. Daniel Woodford- Chair
Dr. Jeff Frazier- Chair
Dr. Kenneth McDowell- Chair
Dr. Gregory Szlyk- Chair
Dr. Kurian Thott- Chair
|
Types of ACO Participants, or Combinations of Participants, That Formed the ACO:
- Networks of individual practices of ACO professionals
- Partnerships or joint venture arrangements between hospitals and ACO professionals
Shared Savings and Losses
Amount of Shared Savings/Losses:
-
First Agreement Period
- Performance Year 2022, N/A
Shared Savings Distribution:
-
First 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
Quality Performance Results
2022 Quality Performance Results:
Our ACO did not participate in the Shared Savings Program in the 2021 performance
year, therefore this section is not applicable at this time.
For Previous Years’ Financial and Quality Performance Results, Please Visit data.cms.gov
Payment Rule Waivers
-
Skilled Nursing Facility (SNF) 3-Day Rule Waiver:
- Our ACO uses the SNF 3-Day Rule Waiver, pursuant to 42 CFR § 425.612.
-
Waiver for Payment for Telehealth Services:
- Our ACO clinicians provide telehealth services using the flexibilities
under 42 CFR § 425.612(f) and 42 CFR § 425.613.
Fraud and Abuse Waivers
ACO Pre-Participation Waiver:
Our ACO is not using any Pre-Participation Waivers
ACO Participation Waiver:
The Secretary of the Department of Health and Human Services (HHS) has
made available a participation waiver of federal fraud and abuse laws
in connection with the operation of accountable care organizations (ACOs)
that have entered into a participation agreement under the Medicare Shared
Savings Program (MSSP) with the Centers for Medicare & Medicaid Services (CMS).
The Mary Washington Health Alliance (ACO) Governing Body has duly authorized
the arrangements below and made a bona fide determination that each arrangement
is reasonably related to the purposes of the MSSP because the arrangements
will promote accountability for the quality, cost and overall care for
Medicare beneficiaries assigned to ACO. The descriptions of relevant arrangements
are set forth below for the purpose of ACO availing itself of the protections
afforded under the MSSP Waivers:
- ACO has implemented a care coordination arrangement beginning January 1,
2016, pursuant to which the ACO identifies certain Medicare beneficiaries
as being at high risk or rising risk and actively engages such beneficiaries
under a navigation program constituting an evidenced-based approach to
improving patient engagement and improving the overall efficiency of care.
- ACO has entered into a Hospital Quality and Efficiency Program with Mary
Washington Hospital, of the ACO’s providers/suppliers as of January
1, 2016, for purposes of the implementation by the ACO of quality initiatives
that will support the efficiency and efficacy of various transitions of
care processes in a manner that is transparent to patients, has detailed
quality controls and implements safeguards to ensure compliance with applicable
laws. Specifically, the ACO Governing Body has made a bona fide determination
that the program promotes accountability for the quality and cost of overall
care for Medicare beneficiaries assigned to the ACO.
- The ACO has approved the Surgical Advanced Practitioner Arrangement (the
“Arrangement”) which will begin on or about September 1, 2016.
Under the Arrangement, the ACO will employ a full-time qualified, experienced,
and appropriately licensed allied health professional (e.g., a nurse practitioner
or physician assistant) (“Allied Health Professional”) who
will be located at Mary Washington Hospital (“MWH”) or Stafford
Hospital (“SH”) for the purpose of assisting physician-participants
of the ACO with respect to surgical procedures performed in MWH and SH.
Such duties shall be assigned by the ACO, and may evolve from time to
time, but shall include clinical and administrative activities designed
to optimize the coordination among and engagement of health care team
members and the patient in promotion of the ACO’s quality and cost
objectives.
The Arrangement is designed to promote MWHA’s population health management
capabilities, improve management and coordination of patient care for
Medicare beneficiaries to encompass the hospital setting, and represents
a key investment in MWHA’s infrastructure and redesigned care processes
to achieve high quality and efficient service delivery for patients, including
Medicare beneficiaries. This Arrangement will be located at MWH and SH
for the purpose of assisting physician-participants of MWHA with respect
to surgical procedures performed in MWH and SH. Specifically, the ACO
Governing Body has made a bona fide determination that the program promotes
accountability for the quality and cost of overall care for Medicare beneficiaries
assigned to the ACO.
Mary Washington Health Alliance NextGen ACO (2018-2021)
Mary Washington Health Alliance Accountable Care Organization (ACO)
Medicare ACO's are comprised of groups of doctors, hospitals, and other
health care providers and suppliers who come together voluntarily to provide
coordinated, high-quality care at lower costs to their participating Medicare
patients. The Next Generation ACO Model is an initiative for ACO's
that are experienced in coordinating care for populations of patients.
Mary Washington Health Alliance will build on Mary Washington Healthcare's
(MWHC) rich 100-year history through partnerships with key stakeholders
who share a common mission of improving the health of the population they
serve. After completing three consecutive years in the Medicare Shared
Savings Program and having shown savings and improved quality of care,
the Alliance is ready to take on the road ahead within the Next Generation ACO.
As one of only 58 participants in the Next Generation ACO Model across
the country, the Alliance will be able to build on the current level of
coordinated care and will provide an enhanced quality of care at lower
costs to Medicare patients. The Alliance chose to participate in the Next
Generation ACO Model because we believe that this model allows the best
opportunity to shift patient care away from a clinical model built for
the fee-for-service payment environment and towards a whole-person population
health-focused clinical model. By partnering with their patients in care
decisions, NGACO Participants will achieve the goals of better health
and better care for Medicare beneficiaries.
ACO Name and Location:
Mary Washington Health Alliance, LLC.
2300 Fall Hill Ave.
Suite 308A
Fredericksburg, Virginia 22401
Phone: 540.741.1557
ACO Primary Contact
| Primary Contact Name |
Travis Turner |
| Primary Contact Phone Number |
(540) 741-1557 |
| Primary Contact Email Address |
travis.turner@mwhc.com |
Organizational Information
ACO Participants:
Access Eye
Advanced Digestive Care, LLC
Allergy Partners of Fredericksburg
American Anesthesia Associates
Aquia Family Medical Center
Belmont Aesthetic and Reconstructive Plastic Surgery
BetterMed Urgent Care
Blue Nile Medical Center
Brett Chicko DPM Family Foot and Ankle Center
Cardiology Associates of Fredericksburg
Carriage Hill Health and Rehab
Centercare Family Practice, LLC
Centercare Urgent Care
Central Virginia Anesthesia Anesthesia Concepts
Central Virginia Internal Medicine
Central Virginia OBGYN Group
Central Virginia Orthopedics & Sport Medicine
Central Virginia Podiatry
Central Virginia Sleep Center
Chancellor Internal Medicine
Colonial Internal Medicine Associates PC
Commonwealth Internal Medicine
Cornell J Shelton MD PLLC
DHMR Clinics
Diabetes and Thyroid Associates
Elite Womens Health Inc
ENT & Facial Plastic Surgery of Fredericksburg
Fairfax Medical Clinic LLC
Fall Hill Gastroenterology Associates
Family Care of Fredericksburg
Fredericksburg Anesthesia Services
Fredericksburg Christian Health Center
Fredericksburg Emergency Medical Alliance
Fredericksburg Foot & Ankle Center
Fredericksburg Nephrology Associates
Fredericksburg Women's Health Associates
Gaertner Psychiatric PC
GAF Sedation
Gastroenterology Associates of Fredericksburg
Internal Medicine of Virginia PC
Lee's Hill Family Physicians PC
Mary Washington Cardiology
Mary Washington Dermatology
Mary Washington Endocrinology
Mary Washington Eye Care Center
Mary Washington Family and Internal Medicine
Mary Washington Family Medicine
Mary Washington Family Medicine and Pediatrics
Mary Washington Family Medicine Orange
Mary Washington General Surgery & Trauma
Mary Washington General Surgery Lee’s Hill
Mary Washington Hospitalist Services
Mary Washington Neurology
Mary Washington Neurosurgery
Mary Washington Observation Unit
Mary Washington Obstetrics and Gynecology
Mary Washington Orthopedics
Mary Washington Primary Care
Mary Washington Radiation Oncology
Mary Washington Rheumatology
Mary Washington Sleep Medicine
Mary Washington Spine and Rehabilitation Clinic
Mary Washington Surgical Oncology
Mary Washington Urgent Care
Mary Washington Urology
Mary Washington Virginia Cardiovascular and Thoracic Surgery
Mary Washington Weight Loss Center
McManus & Associates Internal Medicine
Medical Imaging of Fredericksburg
MediDoctors LLC dba Mary Washington Home Health & Hospice
Meridian Independent Physician Group
MetroHealth Internal Medicine PC
Metropolitian Health Care Providers Inc
New Beginnings ObGyn
North Stafford Family Medical Center
Northern Virginia Hematology & Oncology Associates
NOVA Cardiovascular Care, LLC
OBHG Hospitalist
Optimum Care LLC
Oracle Heart & Vascular LLC
Orthopedic Specialty Clinic Ltd
PACS at Ruther Glen
Pathology Associates of Fredericksburg
Plastic Surgery Services
Polaris Heart and Vascular PLLC
Prime Regenerative and Pain Management
Psychiatric Care Inc
Pulmonary Associates of Fredericksburg
Radiation Oncology Specialists of Central Virginia
Radiologic Associates of Fredericksburg
Rapidan Medical Center Inc
Rappahannock Family Healthcare Inc
Rappahannock Women's Health Center Inc
Serenite Medical & Spa
Sieht
Sleep Disorder Center of Fredericksburg
Stafford Internal Medical Services
Stafford Neurology
The Center for Orthopedics
The Dermatology Center
Urology Associates of Fredericksburg
Virginia Cardiovascular Consultants
Virginia Center for Allergy & Asthma
Virginia Dermatology and Skin Surgery Center
Virginia Interventional and Vascular Associates
Virginia Oncology Care, PC
Virginia Urgent Care LLC dba NextCare Urgent Care
Vista Eye
WeCare Medical Associates
William A Hamilton MD
Womens Health and Surgery Center INC
There are no joint ventures between the Alliance ACO and any of its Next
Generation Participants or Preferred Providers.
Key ACO Clinical and Administrative Leadership
ACO Governing Body
|
Travis Turner
|
ACO Executive
|
|
Patrick McManus, MD
|
Medical Director
|
|
Lauren Blalock
|
Compliance Officer
|
|
Daniel Woodford, MD
|
Quality Assurance/Improvement Officer
|
Key ACO clinical and administrative leadership
|
Member
|
Member's Voting Power
|
Membership Type
|
ACO Participant TIN Legal Business Name/DBA, if Applicable
|
|
Last Name
|
First Name
|
Title/Position
|
|
|
|
|
McManus
|
Patrick
|
MD,
Chairman/Voting Member
|
1
|
ACO Participant Representative
|
McManus & Associates Internal Medicine, PC
|
|
McDermott
|
Michael
|
MD, Vice Chair/Voting Member
|
1
|
ACO Participant Representative
|
Washington Hospital, Inc., Mary
|
|
Christopher
|
Newman
|
MD,
Secretary/Voting Member
|
1
|
ACO Participant Representative
|
Washington Hospital, Inc., Mary
|
|
Frazier
|
Jeffrey
|
MD,
Treasurer/Voting Member
|
1
|
ACO Participant Representative
|
Radiologic Associates of Fredericksburg, Ltd.
|
|
Vranian
|
Robert
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Virginia Cardiovascular Consultants, PC
|
|
Thott
|
Kurian
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Women’s Health and Surgery Center, Inc.
|
|
Szlyk
|
Gregory
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Urology Associates of Fredericksburg, PC
|
|
Amory
|
Charles
|
MD
|
0
|
Other – Community Physician
|
Chancellor Pediatrics
|
|
DeTrane
|
Frank
|
MD
|
1
|
ACO Participant Representative
|
Gastroenterology
Associates of Fredericksburg
|
|
Vacant
|
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
TBD
|
|
Sims
|
Adam
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Fredericksburg Emergency Medical Alliance, Inc.
|
|
Clemo
|
F. Lynne
|
MD, Voting
Member
|
1
|
ACO Participant
Representative
|
Chancellor Internal
Medicine
|
|
Woodford
|
Daniel
|
MD, Voting Member
|
1
|
ACO Participant Representative
|
Mary Washington Family and Internal Medicine
|
|
McDowell
|
Kenneth
|
DO, Voting Member
|
1
|
ACO Participant Representative
|
Colonial Internal Medicine
|
|
Branscome
|
Ronald
|
Voting Member
|
1
|
|
Medicare Beneficiary Representative
|
|
N/A
|
|
Wilder
|
Martin
|
Voting Member
|
1 |
|
Community Stakeholder Representative
|
|
N/A
|
|
Barden
|
Sean
|
Voting Member
|
1
|
ACO Participant Representative
|
Washington Hospital, Inc., Mary
|
|
Aiken
|
Matthew
|
DO, Voting Member
|
1
|
ACO Participant Representative
|
Mary Washington Hospitalist Services
|
ACO Structure and Committees
Types of ACO Participants or Combinations of Participants that Formed the ACO:
- Networks of individual practices of ACO professionals
- Partnerships or joint venture arrangements between hospitals and ACO professionals
Shared Savings and Losses
Amount of Shared Savings/Losses
- Performance Year 2020, No Savings Achieved
- Performance Year 2019, Lost $1.3 million
- Performance Year 2018, Saved $5.161 million
- Performance Year 2017, Saved $11.997 million shared savings $5.12 million
- Performance Year 2016, Saved $3.75 million shared savings $0
- Performance Year 2015, Saved $3.5 million shared savings $0
Shared Savings Distribution
-
Performance Year 2020
- No savings achieved
- No savings distributed
-
Performance Year 2019
- Proportion Invested in infrastructure TBD
- Proportion invested in redesigned care processes/resources TBD
- Proportion of distribution to ACO participants TBD
-
Performance Year 2018
- Proportion Invested in infrastructure TBD
- Proportion invested in redesigned care processes/resources TBD
- Proportion of distribution to ACO participants TBD
-
Performance Year 2017
- Proportion invested in infrastructure TBD
- Proportion invested in redesigned care processes/resources TBD
- Proportion of distribution to ACO participants TBD
-
Performance Year 2016
- Proportion invested in infrastructure: N/A
- Proportion invested in redesigned care processes/resources: N/A
- Proportion of distribution to ACO participants: N/A
-
Performance Year 2015
- Proportion invested in infrastructure: N/A
- Proportion invested in redesigned care processes/resources: N/A
- Proportion of distribution to ACO participants: N/A
2020 Quality Performance Results Table
| Table 1. Summary Information |
|
|
|
|
|
|
|
| Domain |
Points Earned without Quality Improvement Points |
Domain Improvement Score [1]
(%)
|
Quality Improvement Reward Points [2] |
Points Earned with Quality Improvement Reward Points [3] |
Domain Score
(%)
|
Quality Performance Standard Status: Completely Reported |
Quality Performance Standard Status [4]: Minimum Attainment Met
(% measures in domain)
|
| Patient/Caregiver Experience |
20.00 |
Not Applicable |
Not Applicable |
20.00 |
100.00 |
Not Applicable |
Not Applicable |
| Care Coordination/Patient Safety |
7.85 |
-100.00 |
0.00 |
7.85 |
98.13 |
Yes |
100.0 |
| Preventive Health |
11.10 |
33.33 |
1.36 |
12.00 |
100.00 |
Yes |
100.0 |
| At-Risk Population |
5.55 |
-33.33 |
0.00 |
5.55 |
92.50 |
Yes |
100.0 |
| Table 2. Patient/Caregiver Experience |
|
|
|
|
|
|
|
|
|
|
|
|
|
| ACOs were not required to field a CAHPS survey due to the Public Health
Emergency and will receive full credit for all 10 CAHPS measures: ACO-1,
ACO-2 ,ACO-3, ACO-4, ACO-5, ACO-6, ACO-7, ACO-34, ACO-45 and ACO-46. |
|
|
|
| Thus, for the PCE domain all ACOs will earn 20/20 points. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Table 3. Care Coordination/Patient Safety |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
Numerator |
Denominator |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [1,2] |
Points Earned [3] |
Total Possible Points |
Prior Year Performance Rate |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-8 [4] |
Risk-Standardized, All Condition Readmission |
R |
--- |
--- |
16.07 |
Yes |
Not Applicable |
2.00 |
2.00 |
16.27 |
15.05 |
15.07 |
N/A |
N/A |
| ACO-38 [4,5] |
Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic
Conditions |
R |
--- |
--- |
62.98 |
Yes |
Not Applicable |
2.00 |
2.00 |
73.73 |
47.97 |
49.39 |
N/A |
N/A |
| ACO-43 [6] |
Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality
Indicator [PQI] #91) (version with additional Risk Adjustment) |
R |
--- |
--- |
1.39 |
Yes |
Not Applicable |
2.00 |
2.00 |
2.77 |
0.87 |
0.95 |
N/A |
N/A |
| ACO-13 |
Falls: Screening for Future Falls Risk |
P |
530 |
599 |
88.48 |
Yes |
Significant Decline |
1.85 |
2.00 |
92.08 |
85.63 |
85.00 |
30.00 |
90.00 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Table 4. Preventive Health |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
Numerator |
Denominator |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [1,2] |
Points Earned [3] |
Total Possible Points |
Prior Year Performance Rate |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-14 |
Preventive Care and Screening: Influenza Immunization |
P |
394 |
562 |
70.11 |
Yes |
Significant Improvement |
1.70 |
2.00 |
62.53 |
76.05 |
76.03 |
30.00 |
90.00 |
| ACO-17 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
P |
19 |
23 |
82.61 |
Yes |
No Significant Change |
1.85 |
2.00 |
82.61 |
78.61 |
81.53 |
30.00 |
90.00 |
| ACO-18 |
Preventive Care and Screening: Screening for Depression and Follow-up Plan |
R |
286 |
472 |
60.59 |
Yes |
No Significant Change |
2.00 |
2.00 |
62.99 |
70.66 |
71.42 |
N/A |
N/A |
| ACO-19 |
Colorectal Cancer Screening |
P |
249 |
334 |
74.55 |
Yes |
No Significant Change |
1.70 |
2.00 |
76.00 |
73.28 |
72.62 |
30.00 |
90.00 |
| ACO-20 |
Breast Cancer Screening |
P |
212 |
250 |
84.80 |
Yes |
Significant Improvement |
1.85 |
2.00 |
76.72 |
74.85 |
74.08 |
30.00 |
90.00 |
| ACO-42 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
R |
316 |
345 |
91.59 |
Yes |
No Significant Change |
2.00 |
2.00 |
90.07 |
81.04 |
83.27 |
N/A |
N/A |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Table 5. At-Risk Population |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
Numerator |
Denominator |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [1,2] |
Points Earned [3] |
Total Possible Points |
Prior Year Performance Rate |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-40 |
Depression Remission at Twelve Months |
R |
3 |
32 |
9.38 |
Yes |
No Significant Change |
2.00 |
2.00 |
0.00 |
11.41 |
13.88 |
N/A |
N/A |
| ACO-27 |
Diabetes Mellitus: Hemoglobin A1c Poor Control |
P |
50 |
314 |
15.92 |
Yes |
Significant Decline |
1.85 |
2.00 |
11.58 |
13.95 |
14.67 |
70.00 |
10.00 |
| ACO-28 |
Hypertension (HTN): Controlling High Blood Pressure |
P |
186 |
251 |
74.10 |
Yes |
No Significant Change |
1.70 |
2.00 |
71.05 |
73.11 |
72.88 |
30.00 |
90.00 |
2019 Quality Performance Results Table
| Table 1. Summary Information |
|
|
|
|
|
|
|
| Domain |
Points Earned without Quality Improvement Points |
Domain Improvement Score [1]
(%)
|
Quality Improvement Reward Points [2] |
Points Earned with Quality Improvement Reward Points [3] |
Domain Score
(%)
|
Quality Performance Standard Status: Completely Reported |
Quality Performance Standard Status [4]: Minimum Attainment Met
(% measures in domain)
|
| Patient/Caregiver Experience |
17.90 |
0.00 |
0.00 |
17.90 |
89.50 |
Yes |
100.00 |
| Care Coordination/Patient Safety |
6.00 |
-50.00 |
0.00 |
6.00 |
75.00 |
Yes |
75.00 |
| Preventive Health |
12.00 |
33.33 |
1.36 |
12.00 |
100.00 |
Yes |
100.00 |
| At-Risk Population |
5.55 |
66.67 |
2.68 |
6.00 |
100.00 |
Yes |
100.00 |
| Table 2. Patient/Caregiver Experience [1] |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
--- |
Number of Surveys Completed |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [2,3] |
Points Earned [4] |
Total Possible Points |
Prior Year Performance Rate |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-1 |
CAHPS: Getting Timely Care, Appointments, and Information |
P |
--- |
280 |
85.22 |
Yes |
No Significant Change |
1.85 |
2.00 |
83.64 |
86.03 |
85.88 |
30.00 |
90.00 |
| ACO-2 |
CAHPS: How Well Your Providers Communicate |
P |
--- |
310 |
94.48 |
Yes |
No Significant Change |
2.00 |
2.00 |
93.93 |
94.11 |
94.11 |
30.00 |
90.00 |
| ACO-3 |
CAHPS: Patients’ Rating of Provider |
P |
--- |
301 |
93.34 |
Yes |
No Significant Change |
2.00 |
2.00 |
91.47 |
92.75 |
92.70 |
30.00 |
90.00 |
| ACO-4 |
CAHPS: Access to Specialists |
P |
--- |
210 |
81.41 |
Yes |
No Significant Change |
1.85 |
2.00 |
80.41 |
80.97 |
81.48 |
30.00 |
90.00 |
| ACO-5 |
CAHPS: Health Promotion and Education |
P |
--- |
328 |
54.84 |
Yes |
No Significant Change |
1.10 |
2.00 |
52.69 |
60.46 |
60.44 |
54.18 |
63.44 |
| ACO-6 |
CAHPS: Shared Decision Making |
P |
--- |
298 |
63.69 |
Yes |
No Significant Change |
2.00 |
2.00 |
59.54 |
61.38 |
62.63 |
54.75 |
62.76 |
| ACO-7 |
CAHPS: Health Status/Functional Status |
R |
--- |
333 |
76.63 |
Yes |
No Significant Change |
2.00 |
2.00 |
74.23 |
74.49 |
73.86 |
N/A |
N/A |
| ACO-34 |
CAHPS: Stewardship of Patient Resources |
P |
--- |
321 |
24.86 |
Yes |
No Significant Change |
1.10 |
2.00 |
19.38 |
24.40 |
25.98 |
24.25 |
33.43 |
| ACO-45 |
CAHPS: Courteous and Helpful Office Staff |
R |
--- |
304 |
94.59 |
Yes |
Not Applicable |
2.00 |
2.00 |
--- |
93.05 |
92.86 |
N/A |
N/A |
| ACO-46 |
CAHPS: Care Coordination |
R |
--- |
333 |
88.72 |
Yes |
Not Applicable |
2.00 |
2.00 |
--- |
87.26 |
86.93 |
N/A |
N/A |
| Table 3. Care Coordination/Patient Safety |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
Numerator |
Denominator |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [2,3] |
Points Earned [4]
|
Total Possible Points |
Prior Year Performance Rate |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-8 |
Risk-Standardized, All Condition Readmission |
R |
--- |
--- |
16.27 |
Yes |
Significant Decline |
2.00 |
2.00 |
15.41 |
14.98 |
14.86 |
15.18 |
14.27 |
| ACO-38 |
Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic
Conditions |
R |
--- |
--- |
73.71 |
Yes |
Significant Decline |
2.00 |
2.00 |
69.74 |
56.34 |
58.02 |
65.99 |
41.39 |
| ACO-43 |
Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality
Indicator [PQI] #91) (version with additional Risk Adjustment) |
P |
--- |
--- |
2.77 |
Yes |
Significant Decline |
0.00 |
2.00 |
2.73 |
1.72 |
1.86 |
1.95 |
1.51 |
| ACO-13 |
Falls: Screening for Future Falls Risk |
P |
407 |
442 |
92.08 |
Yes |
Significant Improvement |
2.00 |
2.00 |
88.85 |
88.97 |
84.39 |
43.42 |
90.73 |
| Table 4. Preventive Health |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
Numerator |
Denominator |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [2,3] |
Points Earned [4]
|
Total Possible Points |
Prior Year Performance Rate [5] |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-14 |
Preventive Care and Screening: Influenza Immunization |
R |
242 |
387 |
62.53 |
Yes |
Not Applicable |
2.00 |
2.00 |
61.24 |
76.98 |
74.93 |
N/A |
N/A |
| ACO-17 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
R |
19 |
23 |
82.61 |
Yes |
Not Applicable |
2.00 |
2.00 |
43.24 |
79.60 |
78.15 |
N/A |
N/A |
| ACO-18 |
Preventive Care and Screening: Screening for Depression and Follow-up Plan |
R |
274 |
435 |
62.99 |
Yes |
Not Applicable |
2.00 |
2.00 |
46.35 |
73.00 |
70.59 |
N/A |
N/A |
| ACO-19 |
Colorectal Cancer Screening |
R |
247 |
325 |
76.00 |
Yes |
No Significant Change |
2.00 |
2.00 |
72.76 |
77.12 |
71.22 |
30.00 |
90.00 |
| ACO-20 |
Breast Cancer Screening |
R |
290 |
378 |
76.72 |
Yes |
No Significant Change |
2.00 |
2.00 |
73.79 |
79.31 |
74.23 |
30.00 |
90.00 |
| ACO-42 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
R |
254 |
282 |
90.07 |
Yes |
Significant Improvement |
2.00 |
2.00 |
84.49 |
82.43 |
82.19 |
N/A |
N/A |
| Table 5. At-Risk Population |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Measure Number |
Measure Name |
P4P or P4R |
Numerator |
Denominator |
Your ACO Performance Rate |
Completely Reported? |
Quality Improvement Reward Information [2,3] |
Points Earned [4] |
Total Possible Points |
Prior Year Performance Rate |
Current Year Mean Performance Rate (NextGen ACOs) |
Current Year Mean Performance Rate (All ACOs) |
30th Percentile Benchmark |
90th Percentile Benchmark |
| ACO-40 |
Depression Remission at Twelve Months |
R |
0 |
26 |
0.00 |
Yes |
No Significant Change |
2.00 |
2.00 |
0.00 |
11.82 |
13.45 |
N/A |
N/A |
| ACO-27 [6] |
Diabetes Mellitus: Hemoglobin A1c (HbA1c) Poor Control (>9%) |
P |
52 |
449 |
11.58 |
Yes |
Significant Improvement |
1.85 |
2.00 |
18.84 |
11.43 |
13.71 |
70.00 |
10.00 |
| ACO-28 |
Hypertension: Controlling High Blood Pressure |
P |
324 |
456 |
71.05 |
Yes |
Significant Improvement |
1.70 |
2.00 |
66.12 |
78.62 |
75.30 |
30.00 |
90.00 |
2018 Quality Performance Results Table
| Table 2. Patient/Caregiver Experience |
|
|
|
| Measure Number |
Measure Name |
P4P or P4R* |
Your ACO Performance Rate* |
| ACO-1 |
CAHPS: Getting Timely Care, Appointments, and Information |
P |
83.64 |
| ACO-2 |
CAHPS: How Well Your Providers Communicate |
P |
93.93 |
| ACO-3 |
CAHPS: Patients’ Rating of Provider |
P |
91.47 |
| ACO-4 |
CAHPS: Access to Specialists |
P |
80.41 |
| ACO-5 |
CAHPS: Health Promotion and Education |
P |
52.69 |
| ACO-6 |
CAHPS: Shared Decision Making |
P |
59.54 |
| ACO-7 |
CAHPS: Health Status/Functional Status |
R |
74.23 |
| ACO-34 |
CAHPS: Stewardship of Patient Resources |
R |
19.38 |
|
|
|
|
| Table 3. Care Coordination/Patient Safety |
|
|
|
| Measure Number |
Measure Name |
P4P or P4R* |
Your ACO Performance Rate* |
| ACO-8 |
Risk Standardized, All Condition Readmission |
P |
15.41 |
| ACO-35 |
Skilled Nursing Facility 30-day All-Cause Readmission measure (SNFRM) |
R |
19.67 |
| ACO-36 |
All-Cause Unplanned Admissions for Patients with Diabetes |
R |
42.58 |
| ACO-37 |
All-Cause Unplanned Admissions for Patients with Heart Failure |
R |
86.91 |
| ACO-38 |
All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions |
R |
69.74 |
| ACO-43 |
Ambulatory Sensitive Condition Acute Composite (AHRQ* Prevention Quality
Indicator (PQI #91)) |
R |
2.35 |
| ACO-12 |
Medication Reconciliation |
R |
32.77% |
| ACO-13 |
Falls: Screening for Future Fall Risk |
P |
88.85% |
| ACO-44 |
Imaging Studies for Low Back Pain |
R |
88.89% |
|
|
|
|
| Table 4. Preventive Health |
|
|
|
| Measure Number |
Measure Name |
P4P or P4R* |
Your ACO Performance Rate* |
| ACO-14 |
Preventive Care and Screening: Influenza Immunization |
P |
61.24% |
| ACO-15 |
Pneumonia Vaccination Status for Older Adults |
P |
81.09% |
| ACO-16 |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up |
P |
59.68% |
| ACO-17 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
P |
43.24% |
| ACO-18 |
Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan |
P |
46.35% |
| ACO-19 |
Colorectal Cancer Screening |
P |
72.76% |
| ACO-20 |
Breast Cancer Screening |
P |
73.79% |
| ACO-42 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
R |
84.49% |
|
|
|
|
| Table 5. At-Risk Population |
|
|
|
| Measure Number |
Measure Name |
P4P or P4R* |
Your ACO Performance Rate* |
| ACO-40 |
Depression Remission at Twelve Months |
R |
0.00% |
| Diabetes Composite |
Diabetes Composite (All or Nothing Scoring) |
R |
40.22% |
| ACO-27 |
Diabetes Mellitus: Hemoglobin A1c Poor Control |
R |
18.84% |
| ACO-41 |
Diabetes: Eye Exam |
R |
46.74% |
| ACO-28 |
Hypertension (HTN): Controlling High Blood Pressure |
P |
66.12% |
| ACO-30 |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic |
P |
91.08% |
| ACO-43 |
Ambulatory Sensitive Condition Acute Composite |
|
2.73% |
2017 Quality Performance Results Table
2016 Quality Performance Results Table
|
ACO#
|
Measure Number
|
Rate
|
ACO Mean
|
| ACO-1 |
CAHPS: Getting Timely Care, Appointments, and Information |
92.62 |
92.63 |
| ACO-2 |
CAHPS: How Well Your Providers Communicate |
92.15 |
91.93 |
| ACO-3 |
CAHPS: Patients' Rating of Provider |
82.7 |
83.52 |
| ACO-4 |
CAHPS: Access to Specialists |
57.43 |
60 |
| ACO-5 |
CAHPS: Health Promotion and Education |
74.36 |
75.28 |
| ACO-6 |
CAHPS: Shared Decision Making |
74.36 |
75.28 |
| ACO-7 |
CAHPS: Health Status/Functional Status |
72.39 |
71.82 |
| ACO-34 |
CAHPS: Stewardship of Patient Resources |
26.6 |
27.52 |
| ACO-8 |
Risk-Standardized, All Condition Readmission |
14.74 |
14.7 |
| ACO-35 |
Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) |
18.58 |
18.17 |
| ACO-36 |
All-Cause Unplanned Admissions for Patients with Diabetes |
53.25 |
53.2 |
| ACO-37 |
All-Cause Unplanned Admissions for Patients with Heart Failure |
73.97 |
75.23 |
| ACO-38 |
All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions |
59.54 |
59.81 |
| ACO-9 |
Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary
Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5) |
16.55 |
9.27 |
| ACO-10 |
Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention
Quality Indicator (PQI) #8 ) |
17.4 |
14.53 |
| ACO-11 |
Percent of PCPs who Successfully Meet Meaningful Use Requirements |
85.71 |
82.72 |
| ACO-39 |
Documentation of Current Medications in the Medical Record |
92.36 |
87.54 |
| ACO-13 |
Falls: Screening for Future Fall Risk |
59.04 |
64.04 |
| ACO-14 |
Preventive Care and Screening: Influenza Immunization |
56.05 |
68.32 |
| ACO-15 |
Pneumonia Vaccination Status for Older Adults |
78.71 |
69.21 |
| ACO-16 |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow Up |
82.14 |
74.45 |
| ACO-17 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
95 |
90.98 |
| ACO-18 |
Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan |
30.68 |
53.63 |
| ACO-19 |
Colorectal Cancer Screening |
68.8 |
61.52 |
| ACO-20 |
Breast Cancer Screening |
45.01 |
67.61 |
| ACO-21 |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-up
Documented |
76.53 |
76.84 |
| ACO-42 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
81.12 |
77.72 |
| ACO-27 |
Diabetes Mellitus: Hemoglobin A1c Poor Control |
15.41 |
18.24 |
| ACO-41 |
Diabetes: Eye Exam |
57.52 |
44.94 |
| ACO-28 |
Hypertension (HTN): Controlling High Blood Pressure |
77.42 |
70.52 |
| ACO-30 |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic |
90.91 |
85.05 |
| ACO-31 |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD) |
98.79 |
88.67 |
| ACO-33 |
Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker
(ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular
Systolic Dysfunction (LVEF<40%) |
74.23 |
79.67 |
2016 Quality Performance Results Table
Please note, the ACO-40 Depression Remission at 12 months quality measure
is not included in public reporting due to low samples.
Note: In the Quality Performance Results file(s) above, search for “Mary
Washington Health Alliance, LLC.” to view the quality performance
results. This ACO can also be found by using the ACO ID A07732 in the
public use files on data.cms.gov.
For more information: