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
MARY WASHINGTON MEDICAL GROUP HOSPITALIST SERVICES, LLC N
MARY WASHINGTON HEALTHCARE PHYSICIANS N
RADIOLOGIC ASSOCIATES OF FREDERICKSBURG N
MEDICAL IMAGING OF FREDERICKSBURG, LLC N
VIRGINIA URGENT CARE LLC N
STAFFORD HOSPITAL, LLC N
EMERGENCY PHYSICIANS IMMEDIATE CARE CENTER 2 LLC N
OBHG VIRGINIA LLC N
ELITE WOMENS HEALTH INC N
MARY WASHINGTON HOSPITAL INC N
ACCESS EYE CENTERS, PC N
CENTERCARE FAMILY PRACTICE LLC N
RAPPAHANNOCK WOMEN'S HEALTH CENTER PC N
GAERTNER PSYCHIATRIC, PC N
VIRGINIA CENTER FOR ALLERGY AND ASTHMA INC. N
FREDERICKSBURG EMERGENCY MEDICAL ALLIANCE, INC. N
GASTROENTEROLOGY ASSOCIATES OF FREDERICKSBURG, P.C. N
VIRGINIA DERMATOLOGY AND SKIN SURGERY CENTER N
Polaris Heart and Vascular, PLLC. N
CARDIOLOGY ASSOCIATES OF FREDERICKSBURG, LTD. N
UROLOGY ASSOCIATES OF FREDERICKSBURG, PC N
MEDIDOCTORS LLC N
CENTRAL VIRGINIA ORTHOPAEDICS & SPORTS MEDICINE N
PATHOLOGY ASSOCIATES OF FREDERICKSBURG PTR N
COLONIAL INTERNAL MEDICINE ASSOCIATES PC N
CORNELL J SHELTON MD PLLC N
VIRGINIA ONCOLOGY CARE PC N
FALL HILL GASTROENTEROLOGY ASSOCIATES, LTD. N
DERMATOLOGY CENTER PC N
VIRGINIA CARDIOVASCULAR CONSULTANTS PC N
ORTHOPEDIC SPECIALTY CLINIC LTD N
CENTRAL VIRGINIA OB GYN GROUP PC N
ORACLE HEART & VASCULAR PLLC N
LEE'S HILL FAMILY PHYSICIANS, P.C. N
PULMONARY ASSOCIATES OF FREDERICKSBURG N
CENTRAL VIRGINIA ANESTHESIA LLC N
EAR NOSE AND THROAT AND FACIAL PLASTIC SURGERY CENTER OF FREDERICK N
NEW BEGINNINGS OB GYN PC N
Chancellor Internal Medicine N
CENTRAL VIRGINIA INTERNAL MEDICINE PLC N
WOMENS HEALTH AND SURGERY CENTER N
OPTIMUM CARE LLC N
MEDICAL & URGENT CARE CENTER, PC N
Fredericksburg Christian Health Center N
PEDSPLUS URGENT CARE LLC N
MAP RC LLC N
FREDERICKSBURG ANESTHESIA SERVICES LLC N
METROPOLITAN HEALTH CARE PROVIDERS, INC. N
VISTA EYE SPECIALISTS PC N
NORTHERN VIRGINIA HEMATOLOGY ONCOLOGY ASSOCIATES PC N
BLUE NILE MEDICAL CENTER, P.C. N
THE CENTER FOR ORTHOPEDICS, INC. N
COMMONWEALTH INTERNAL MEDICINE PC N
SLEEP DISORDER CENTER OF FREDERICKSBURG PLC N
CENTRAL VIRGINIA SLEEP CENTER PLC N
MARY WASHINGTON EYE CARE CENTER, LLC N
METROHEALTH INTERNAL MEDICINE, PC N
FAMILY FOOT AND ANKLE CENTER N
RADIATION ONCOLOGY SPECIALISTS OF CENTRAL VIRGINIA PLC N
LEF, PC N
RAPIDAN MEDICAL CENTER N
FAMILY CARE OF FREDERICKSBURG PLC N
WILLIAM HAMILTON N
SERENITE MEDICAL & SPA INC N
INTERNAL MEDICINE OF VIRGINIA, P.C. N
FREDERICKSBURG FOOT & ANKLE CENTER N
MCMANUS & ASSOCIATES INTERNAL MEDICINE PC N
DIABETES & THYROID ASSOCIATES N
CHANCELLOR PRIMARY CARE PLLC N
BELMONT AESTHETIC & RECONSTRUCTIVE PLASTIC SURGERY N
PSYCHIATRIC CARE INC N
DHMR CLINICS, INC N
WECARE MEDICAL ASSOCIATES N

Key ACO Clinical and Administrative Leadership:

ACO Governing Body:


ACO Executive: Travis Turner

Medical Director: Richard Lewis, MD

Compliance Officer: Lauren Blalock

Quality Assurance/Improvement Officer: Daniel Woodford, MD

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

Mary Washington Hospital, Inc.

Newman

Christopher

MD,

Secretary/Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

Frazier

Jeffrey

MD,

Treasurer/Voting Member

1

ACO Participant Representative

Radiologic Associates of Fredericksburg, Ltd.
Nakave Abhijeet

MD, Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

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.

Woodford

Daniel

MD,

Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

McDowell

Kenneth

MD,

Voting Member

1

ACO Participant Representative

Colonial Internal Medicine Associates PC
Gamache Donna

MD, Voting Member

1

ACO Participant Representative

Lee's Hill Family Physicians, PC

Brown

Dana

MD, Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

Sherwood

Timothy

MD, Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

Aiken

Matthew

DO, Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

Branscome

Ronald

MD, Voting Member

1

Medicare Beneficiary Representative

N/A

Wilder

 Martin

MD, Voting Member

1

Community Stakeholder Representative

N/A

Barden

Sean

MD, Voting Member

1

ACO Participant Representative

Mary Washington Hospital, Inc.

Associated Committees and Committee Leadership:

  • Patrick McManus, MD; MWMD Board Chair
  • Daniel Woodford, MD; Chair, Clinical Quality Committee
  • Kurian Thott, MD; Chair, Communications and Education Committee
  • Jeffrey Frazier, MD; Chair, Finance and Contracting Committee
  • Gregory Szlyk, MD; Chair, Information Technology Committee
  • Kenneth McDowell, DO; Chair, Nominating and Membership/Operations 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:

  • 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:

  1. 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.
  2. 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.
  3. 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.

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.

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