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:
- 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.
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 |
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|
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|
|
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 |
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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. |
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|
Thus, for the PCE domain all ACOs will earn 20/20 points. |
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Table 3. Care Coordination/Patient Safety |
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|
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 |
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Table 4. Preventive Health |
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|
|
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 |
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Table 5. At-Risk Population |
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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 |
|
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|
|
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] |
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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: